Failure to Update Care Plan After Reported Staff Inability to Meet Needs and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a reported change of condition and allegation of staff misconduct for one resident. The facility’s policy on Comprehensive Care Plans requires that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, including the resident and representative when applicable. For this resident, an SBAR: Change of Condition dated 1/31/26 documented that the resident’s daughter reported a CNA was unable to meet the resident’s needs and was harassing the resident. Despite this documented change of condition and allegation, review of the resident’s plan of care showed no care plan problem was developed to address the daughter’s report that staff were not meeting the resident’s needs and the allegation of harassment. During interviews and concurrent medical record reviews, LVN 2 and LVN 3 each verified that no care plan problem had been developed following the reported change of condition on 1/31/26. LVN 2 stated that the purpose of developing a care plan related to a change of condition is to ensure goals and interventions are being met or revised as needed, and LVN 3 stated that the importance of a care plan is to create and update resident goals and interventions as needed. The Administrator was later informed of and acknowledged these findings. The facility’s inaction in updating the care plan after the documented report from the resident’s daughter constituted a failure to develop a comprehensive care plan that reflected the resident’s individual care needs and the reported concerns.
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