F0657

D

Failure to Reassess and Revise Care Plans After Resident-to-Resident Aggression

Merced, California Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely reassess and revise comprehensive, person‑centered care plans for two residents after a significant behavioral incident involving resident‑to‑resident aggression. On 3/13/26, one resident (Res 1), a female with chronic kidney disease stage 3, hypertension, heart failure, type 2 diabetes, atrial fibrillation, malignant pleural effusion, anxiety disorder, depression, hypothyroidism, generalized muscle weakness, and difficulty walking, was observed yelling at other residents and pushing another resident’s (Res 2’s) wheelchair near the nursing station. Res 2, a 61‑year‑old male with hemiplegia and hemiparesis following cerebral infarction affecting the left side, dysphagia, generalized muscle weakness, difficulty walking, a left rib fracture, benign neoplasm of the meninges, nicotine dependence, a cerebrospinal fluid drainage device, and a history of falling, became upset and kicked Res 1’s wheelchair. Staff, including LVN 1, intervened, separated the residents, and moved Res 2 to the patio area while Res 1 remained near the nurses’ station, continuing to yell at staff.

Following the incident, LVN 1 documented in Res 1’s nursing note that Res 1 had an episode of behavior with another resident, pushed Res 2’s wheelchair, and that Res 2 kicked Res 1’s wheelchair. The note indicated that both residents were separated, no physical contact was made between their bodies, and that Res 1 continued yelling at staff and attempted to reach toward the nurse. LVN 1 reported performing a head‑to‑toe assessment and mental‑health check on Res 2 and attempting to assess Res 1, but acknowledged she did not document any assessment or notes in Res 2’s medical record. Interviews with the Social Services Director, MDS coordinator, Director of Staffing Development, and DON confirmed that Res 2’s electronic medical record contained no nursing assessment, no nurses’ notes, no care plan updates, and no IDT documentation related to the 3/13/26 incident, despite the expectation that both residents would be assessed and that care plans and IDT notes would reflect the event and any new interventions.

For Res 1, the MDS coordinator and Social Services Director identified that the care plan had been updated only to address behaviors of making false statements toward residents and staff, but not to address the documented aggressive behavior toward another resident and staff, nor the incident of Res 2 kicking Res 1’s wheelchair. There was no IDT documentation discussing the aggressive behavior, the pushing of another resident’s wheelchair, or any planned interventions to ensure safety and manage behaviors after the incident. Social services staff and the Administrator stated they followed up and interviewed staff present during the event, but these actions were not documented. The facility’s policies on comprehensive, person‑centered care planning and on abuse investigation and reporting require ongoing assessments, timely care plan revisions when residents’ conditions or behaviors change, and thorough documentation of investigations and findings. The lack of documented reassessment, care plan revision, and IDT planning for both residents after the 3/13/26 resident‑to‑resident aggression constituted the cited deficiency and was identified as placing both residents at risk for psychosocial distress and for not being comprehensively reassessed for appropriate individualized services to assure their highest practicable physical, mental, and psychosocial well‑being.