Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan in response to repeated resident-to-resident incidents and newly implemented staff interventions. Resident #7 was admitted on 11/15/22 with diagnoses including COPD, major depressive disorder, chronic viral hepatitis, mild dementia, and type 2 diabetes. Resident #13, admitted on 01/30/24 with cerebral palsy, osteogenesis imperfecta, type 2 diabetes, major depressive disorder, need for assistance with personal care, convulsions, and aortic stenosis, was involved in two separate incidents with Resident #7 in Resident #13’s room. A nursing note dated 09/27/25 documented that Resident #7 was found in Resident #13’s room, after which staff verbally instructed Resident #7 not to enter Resident #13’s room and demonstrated an alternate route to the back of the facility for smoking and activities so he could avoid passing by Resident #13’s room. A self-reported incident dated 12/07/25 showed a second incident in which Resident #7 was again found in Resident #13’s room and was reminded by staff that he could not be there and needed to leave. Review of Resident #7’s care plan, with a review date of 12/23/25, showed an identified problem of alteration in cognitive function secondary to dementia, with interventions such as assisting with decision making, monitoring for changes in condition and cognition, and offering verbal reminders and cues. However, the care plan contained no revisions to reflect the two resident-to-resident incidents on 09/27/25 and 12/07/25, nor did it include the specific interventions directing Resident #7 not to enter Resident #13’s room or to use the alternate route to the back of the facility. A quarterly MDS 3.0 assessment for Resident #7 indicated he was cognitively intact, did not exhibit behavior symptoms or rejection of care, was independent with transfers, could self-propel in his wheelchair, and required setup to moderate assistance for ADLs. In an interview, the DON confirmed there were two incidents between the residents in Resident #13’s room, that Resident #7 had been educated about not entering that room and about using an alternative route, and that these interventions were not added to Resident #7’s care plan.
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