Failure to Timely Update Care Plan After Aggressive and Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan in a timely manner following significant behavioral incidents, including a resident-to-resident altercation and subsequent physical aggression toward staff. The facility’s policy required the comprehensive care plan to be reviewed and revised as necessary when a resident experienced a status change. The resident, who had dementia, a UTI, altered mental status, a BIMS score of 3/15 indicating severe cognitive impairment, and an activated POA for healthcare, was involved in a physical and verbal altercation with another resident. Following this incident, the resident was placed on 15‑minute checks and moved to a different unit, but the care plan in the electronic medical record did not reflect a history of physical and verbal aggression toward residents and staff. Progress notes documented that the resident was physically aggressive with staff, including an incident where the resident punched, grabbed, and twisted a staff member’s breast, laughed, and refused to let go, as well as multiple other notes of physical aggression toward staff. When the surveyor reviewed the care plan in the electronic record, it lacked any mention of the resident’s aggression or inappropriate grabbing of staff. Paper copies later provided by the NHA showed care plans and interventions all dated as created on the date of the initial incident, including new entries describing confusion, episodes of physical aggression, and interventions such as redirection, 1:1 activities, and contacting the spouse during high agitation. However, the electronic record’s history showed that these aggression-related care plan elements and interventions were actually created and updated on a later survey date, revealing a discrepancy between the electronic care plan history and the dates printed on the paper copies.
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