Failure to Develop Communication and Behavior Care Plans for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive care plan addressing communication and behavioral needs for one resident. The resident was admitted on a specified date, and behavior monitoring and intervention reports documented multiple episodes of problematic behaviors, including grabbing others, hitting others, physical aggression toward others, agitation, anxiousness, and exit-seeking on consecutive days. The admission MDS assessment indicated the resident had adequate hearing with hearing aids, was usually understood and usually understood others, and showed no behaviors at that time. The Care Area Assessment (CAA) summary, completed shortly after admission by the previous Social Work Assistant, showed that communication was a triggered care area and stated that communication would be addressed in the care plan. Despite these findings, review of the resident’s care plan, dated shortly after admission with a later revision date, revealed no care plan or interventions in the areas of communication or behaviors. In a telephone interview, the previous Social Work Assistant confirmed she completed the communication CAA summary and acknowledged the resident should have had a communication care plan, but she did not know why one had not been developed. She stated she based her CAA answers solely on the resident’s behavior during the assessment, when no behaviors were observed, and she did not review the electronic medical record’s behavioral monitoring and intervention report because she did not know she needed to do so. The DON also stated that the resident should have had communication and behavior care plans and was unsure why they had not been completed.
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