F0656

E

Failure to Maintain Current, Comprehensive Care Plans for Residents With Behaviors, Falls, and Abuse Risk

East Chicago, Indiana Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and update comprehensive, measurable care plans with current interventions for multiple residents with behaviors, falls, schizophrenia, and abuse/neglect risk. For one resident with Alzheimer’s disease, psychotic disorder, depression, COPD, and cognitive impairment, the record showed two facility-reported incidents: a candy-related interaction with another resident where no injuries occurred, and a later verbal altercation with a different resident that resulted in the resident being found on the floor with right leg and hip pain and being sent to the hospital. Despite these events and existing care plans for elopement/wandering, abuse/neglect risk, and falls, the interventions within these care plans had not been revised for many months, with the elopement/wandering interventions last revised in June of the prior year, the abuse/neglect interventions unchanged since May of the prior year, and the fall interventions last updated in July of the prior year.

Another resident with schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse had multiple documented episodes of verbally aggressive behavior toward staff and residents over several dates. Nursing notes documented the use of 30‑minute checks and later 15‑minute safety checks, as well as two separate hospital transfers for evaluation and behavioral health care. The resident had a behavior care plan that included interventions such as praising progress, protecting the rights and safety of others, minimizing disruptive behaviors, and 15‑minute safety checks. However, the interventions in this behavior care plan were not updated after the series of aggressive behaviors and hospitalizations in December and January; the last intervention prior to the February incident was from September of the previous year, and the care plan interventions were only updated after a later psychiatric hospitalization.

A third resident with suicidal ideations, dementia, anxiety, hypertension, major depressive disorder, and psychotic disorder was involved in the candy-related incident when another resident offered candy and this resident swatted at it, knocking it to the floor, with no injuries noted. This resident had an abuse/neglect risk care plan and a separate care plan for socially inappropriate and maladaptive behavior, but the interventions for abuse/neglect had not been revised since early August of the prior year, and the socially inappropriate/maladaptive behavior interventions had not been revised since mid‑September of the prior year. A fourth resident with hemiplegia, hypotension, paranoid schizophrenia, aphasia, epilepsy, dysphagia, and a right hand contracture was involved in an aggressive incident toward the third resident, after which both residents were assessed and one was sent to the hospital. This fourth resident had an abuse/neglect risk care plan and a schizophrenia care plan, but the abuse/neglect interventions had not been revised since May of the prior year, and the schizophrenia care plan interventions had not been updated since early May of the prior year, despite the later aggressive incident and subsequent care plan revision dates that did not include updated interventions.