Failure to Revise Care Plans and Document IDT Actions After Resident-to-Resident Aggression
Penalty
Summary
The deficiency involves the facility’s failure to timely review and revise comprehensive, person-centered care plans and to document IDT involvement after significant resident-to-resident aggression incidents. The facility’s own policy required ongoing assessment and care plan revision when residents’ conditions or behaviors changed, and when there was a significant change in status. Despite this, after an initial incident in which one male resident with dementia and a history of depression and recurrent subdural hematoma entered another male resident’s room via a shared bathroom, threw items, and grabbed the resident by the ankles, there was no documented update to the aggressor’s care plan. The DON acknowledged that the first incident on 2/20/26 was not reflected in the care plan or IDT notes, even though interventions were reportedly discussed verbally. The second incident occurred the following day, when the same aggressive resident became verbally and physically aggressive toward his new roommate, the roommate’s visiting daughter, and staff, including spitting and throwing objects in the hallway and at others. Nursing notes documented the behaviors and notifications to the MD, responsible party, and law enforcement. The DON confirmed that only the second incident was discussed in IDT notes and that the care plan was reviewed and updated after this second event, not after the first. The facility’s Behavioral Assessment, Intervention and Monitoring policy required that new onset or changes in behavior be documented and that the IDT thoroughly evaluate new or changing behavioral symptoms to identify causes and develop a plan of care, but the first incident was not addressed in this manner. The facility also failed to document IDT review and care plan revisions for the residents who were victims or witnesses to the aggression. For the resident who was grabbed by the ankles, nursing notes documented the event and notifications, and social services later documented that the resident described the assault, expressed feeling safe only if the aggressive resident stayed out of his room, and reported using a wheelchair to block the shared bathroom door. The social services note stated that the IDT was to discuss room changes or other safety measures, but the DON and DMR were unable to find any IDT documentation or follow-up on these recommendations. Another roommate, who witnessed the incident and reported concerns for his roommate’s safety and for other residents, had no nursing assessments, IDT notes, or care plan updates documented related to the event, despite social services noting his concerns. A fourth resident, who was the aggressor’s roommate during the second incident and whose daughter intervened to protect him from the aggressive behavior, also had no documented care plan updates related to the incident, even though he was moved to a different room afterward. These omissions occurred despite facility policies requiring ongoing assessment and care plan revision when residents’ conditions or circumstances changed.
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