Failure to Follow Resident-to-Resident Altercation Policy and Update Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for resident-to-resident altercations after an incident involving Resident 4 on 1/31/2026. Resident 4, who had diagnoses of COPD and CHF and was assessed on the MDS as having no cognitive impairment and being independent with ADLs, was involved in an altercation in which another resident attempted to strike him. Registered Nurse 1 reported that this altercation occurred but stated she did not recall notifying Resident 4’s physician or documenting the incident in Resident 4’s electronic medical record. The Administrator stated she was not aware that the altercation had occurred and confirmed there was no documentation in Resident 4’s EMR indicating that his attending physician had been notified or that a care plan with interventions had been developed to address possible psychosocial needs following the incident. The facility’s policy on Resident-to-Resident Altercations, revised 9/2022, required staff to notify each resident’s attending physician, make necessary changes to the care plan for all residents involved, and document all interventions in the clinical record. These required actions were not carried out for Resident 4 after the altercation.
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