Failure to Clearly Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with a clear focus, goals, and interventions for a resident involved in a staff-to-resident abuse allegation. The resident had diagnoses including other lack of coordination, muscle weakness, need for assistance with personal care, and unspecified dementia without behavioral, psychotic, mood, or anxiety disturbances. A quarterly MDS showed a BIMS score of 9/15, indicating moderately impaired cognition, and documented that the resident was dependent on a helper for transfers from sitting to standing and from chair to bed. Progress notes indicated that the resident complained of back pain and requested to be returned to bed, and staff assisted the resident back to bed. An undated facility document showed that an insurance case worker reported that a CNA was rough with the resident during the transfer to bed and that the resident was saying "ow" during the transfer. The CNA was suspended pending investigation, and the allegation of rough handling was later determined to be unsubstantiated. Review of the resident’s care plan revealed a focus labeled "Documented Resident/Representative Concerns" initiated on the same date as the incident, with interventions limited to the nurse identifying the area of concern, notifying appropriate department leaders per protocol, and notifying Social Services of the concern and possible need for a care conference. The Unit Manager stated that after an abuse allegation, the resident’s care plan should be updated so staff know that allegations were made and what to do, and that he or the DON typically updated care plans. The Regional DON stated that the care plan update for this resident did not meet her expectations and that the issue being addressed was not clear, which did not align with the facility’s policy requiring individualized care plans with measurable objectives and revisions as the resident’s condition dictates.
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