Failure to Revise Care Plan and Orders to Monitor Aggressive Behavior
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include monitoring of aggressive behavior as recommended by the Interdisciplinary Team (IDT). The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was assessed as having modified independence in cognitive skills for daily decision making, with moderate assistance needed for several ADLs. The resident’s history and physical indicated capacity to understand and make decisions. An SBAR dated 11/27/2025 documented that the resident exhibited behavioral symptoms such as agitation when frustrated and when he believed he was being targeted by staff. On 11/28/2025, the IDT met with the resident to address issues related to his verbal aggression toward staff. The IDT Conference Record documented that the team discussed his behavior of verbal aggression and recommended interventions for the plan of care that included continuing to monitor his behavior. However, the resident’s care plan for behavioral symptoms, dated the same day, listed manifestations such as aggressive behavior, verbal abuse, and sudden angry outbursts, but did not include any intervention to monitor these behaviors. LVN 1 confirmed during interview and concurrent record review that the care plan should have been revised to reflect the IDT’s recommendation to monitor the resident’s behavior. Further review of the resident’s active orders on 2/3/2026 showed no orders to monitor for aggressive behavior, verbal abuse, or sudden angry outbursts. LVN 1 stated that a behavior monitoring order would have prompted licensed nurses to document the frequency of behaviors every shift to gather information and determine changes in frequency for physician notification. RN 1 stated that the resident was known to have aggressive behavior and had a 1:1 sitter for safety, and that the IDT’s recommendation to monitor behavior should have been communicated to the physician to obtain an order for every-shift monitoring. RN 1 also stated that the IDT was responsible for updating the care plan so licensed nurses would be aware of the need to monitor and document the frequency of the resident’s aggressive behavior. Facility policies on comprehensive care plans and behavioral assessment indicated that care plans are to be revised as resident information and condition change, and that the IDT evaluates behavioral symptoms and develops a plan of care accordingly.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.