Failure to Involve Guardian in Care Planning and to Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s court‑appointed guardian was invited to and allowed to participate in the care planning process, and the failure to review and revise comprehensive care plans after a resident‑to‑resident abuse incident. One resident with Alzheimer’s disease, severely impaired cognition as evidenced by a Brief Interview for Mental Status score of 3/15, and a legally appointed guardian was readmitted in December 2024. Record review showed quarterly care conferences held on four dates in 2025, with documentation that the guardian participated in only the first conference. The guardian reported not being invited to any meetings to discuss the resident’s care for over a year, and the Social Worker was unable to provide evidence of attempts to notify or involve the guardian in the subsequent three care conferences, limiting the guardian’s ability to participate in development, review, and revision of the resident’s person‑centered care plans. The deficiency also includes the facility’s failure to follow its abuse prohibition policy requiring that staff interventions be carried out and included in the resident’s care plan, and to revise care plans after a resident‑to‑resident abuse incident. One resident with dementia had a care plan initiated in December 2024 for increased episodes of sexually inappropriate behavior toward other residents, with an intervention to seat the resident away from residents of the opposite gender in the dining room. Video footage from November 2025 showed this resident seated between two residents of the opposite gender, including the resident who later struck the resident, while two staff members present did not intervene to follow the seating intervention. Another resident, readmitted with dementia with mood and behavioral disturbance and unspecified psychosis, had a care plan problem indicating mood‑related resident‑to‑resident incidents, but record review did not show that the care plan was revised to include interventions specific to the November 2025 resident‑to‑resident abuse incident. The DNS stated she would have expected the care plan to be updated with new interventions.
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