F0656

E

Failure to Develop and Update Person-Centered Care Plans for Aggressive Behaviors

Paramount, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and update person-centered care plans addressing aggressive behaviors for two residents following admission and readmission. For Resident 1, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, the facility readmitted the resident from a general acute care hospital with aggressive behavior identified as a primary concern. Progress notes from 2/6/2026 through 2/8/2026 documented hyperverbal and aggressive behavior, including yelling, pulling down a privacy curtain, refusing oral medications, throwing medications on the floor, refusing an EKG, being verbally abusive and loud to staff and peers, spitting at a peer on the patio, pacing in the hallway while cursing at staff and other residents, and exhibiting intermittent demanding behavior. An order was in place for safety precautions every 15 minutes for 48 hours related to the readmission, and staff interviews confirmed that Resident 1’s behaviors were more severe than in previous admissions and that no care plan was developed or updated to address these increased aggressive behaviors prior to an altercation with another resident.

The report further notes that Resident 1 was involved in an incident with another resident (Resident 2), who had diagnoses including schizophrenia and convulsions and was cognitively intact, requiring only setup or cleanup assistance for some ADLs and being independent in eating and toileting hygiene. A post-event assessment documented that a CNA witnessed Resident 1 grabbing Resident 2’s wrists during an altercation. Interviews with nursing staff, including an RN and a CNA, confirmed that Resident 1 had exhibited worsening verbal aggression and demanding behaviors in the days leading up to this incident and that the required person-centered care plan upon readmission, which should guide staff in managing such behaviors, had not been developed or updated.

For Resident 6, who had paranoid schizophrenia, intact cognition, and independence in ADLs, psychiatric progress notes dated 1/21/2026 documented that the resident remained oppositional, verbally confrontational with staff, and at moderate risk for aggressive behavior. Staff interviews indicated that this resident was known to be combative and required careful approaches due to safety concerns, and that the resident had a history of aggressive and assaultive behaviors that could result in physical harm to other residents, including neighbors. Despite this, there was no specific care plan developed or updated to address, monitor, or prevent potential future assaultive behaviors. The MDS Coordinator stated that a specific care plan with measurable goals, clearly defined interventions, monitoring parameters, and direction for notifying the physician should have been in place, consistent with the facility’s policy requiring individualized, measurable, resident-centered care plans for behavioral problems.