Failure to Develop and Update Comprehensive Behavior Care Plan for Resident With Recurrent Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s behavioral symptoms and psychosocial needs. The resident had diagnoses of Alzheimer’s disease and bipolar disorder with psychotic features, and the MDS documented moderately impaired cognition. An initial comprehensive care plan noted the resident was pleasant and cooperative but could become agitated and had a history of using racial slurs toward peers and staff; however, no specific interventions were documented. Despite multiple subsequent behavioral incidents, there was no documented evidence that the care plan was updated to address the resident’s behaviors, potential to abuse others, or potential to be a victim of abuse until late in the sequence of events. On one occasion, staff reported the resident threw coffee at staff, which also hit another resident, and the resident used excessive profanity toward staff and residents. On another date, an incident report and investigative summary documented that the resident struck another resident on the cheek after that resident attempted to remove food from the resident’s plate, causing light redness. Nursing progress notes over several days later in the year documented that the resident was refusing medications, including Depakote, using racial slurs, and being physically aggressive toward staff. There was no documented evidence that the care plan was revised to include behavior-specific, person-centered interventions or measurable goals in response to these events. Further incidents included the resident being punched in the mouth by another resident while attempting to clean up a dining table, resulting in a loose lower front tooth, and later attempting to throw a glass vase at staff while using racial slurs before being redirected to their room. Another incident documented that the resident hit the same other resident in the head with a wheelchair leg as that resident ambulated down the hallway, and multiple wheelchair legs were found in the resident’s room. The comprehensive care plan was eventually updated to note a history of altercations and abusing others, but the only intervention listed was redirection, with no additional resident-centered interventions or measurable objectives. Interviews with CNAs, LPNs, RNs, and the DON confirmed that staff recognized the resident’s behavioral issues and history of altercations, but there was no timely or adequate behavior care plan in place, and expected care plan updates after each incident were not completed.
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