Failure to Develop Person-Centered Care Plan After Resident-to-Resident Incident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan with measurable objectives and timeframes to address a resident’s physical and psychosocial needs following an incident with another resident and a subsequent request for psychological support. One resident, admitted with hemiplegia and hemiparesis following a cerebral infarction and documented abnormalities of gait and mobility, had a history and physical indicating capacity to understand and make decisions and an MDS showing mild cognitive impairment and dependence on staff for multiple ADLs, including transfers and walking. On one occasion, this resident was grabbed on the left arm in the hallway by another resident, after which the resident was observed to be shaking and tearing and later reported feeling scared. Record review showed that the Social Services Director requested a psychology consultation for this resident the day after the incident because the resident was having a hard time due to health challenges. However, there was no corresponding care plan developed to address the resident’s psychosocial response to being grabbed or the identified need for psychological consultation. Interviews with the Social Services Director and an LVN confirmed that they were unable to locate any care plan interventions related to the resident’s shaking, tearing, fear after the hallway incident, or the requested psychology consultation. The Director of Nursing also confirmed that no care plan had been created to monitor the resident’s psychosocial well-being in relation to these events. In contrast, the other resident involved in the incident had a documented care plan initiated on the same date as the behavioral episode. This second resident, admitted with metabolic encephalopathy, psychosis, and schizophrenia, had an H&P indicating lack of capacity to make decisions and an MDS showing severe cognitive impairment and need for substantial/maximal assistance with multiple ADLs. Progress notes and an SBAR form documented that this resident was agitated, yelling out, throwing objects, hitting their head against the wall, and grabbing others, including the first resident. A care plan was developed for this resident’s behavioral/psychotic episode, but no corresponding care plan was created for the first resident’s psychosocial needs after being grabbed, despite facility policy requiring a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident’s medical, mental, and psychosocial needs.
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