F0656

E

Failure to Revise Behavioral Care Plan After Repeated Resident Aggression

Irving, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and revise a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with dementia and severe cognitive impairment who exhibited repeated aggressive behaviors toward other residents. Resident #1, an elderly female with diagnoses including dementia, generalized anxiety disorder, diabetes mellitus, and hyperlipidemia, had an admission MDS that did not reflect mood or behavioral symptoms other than often feeling lonely or isolated, and a BIMS score of zero indicating severe cognitive impairment. Her active care plan, with a behavioral symptoms problem initiated months earlier, listed interventions such as reminding her not to call 911, praising appropriate behavior, removing her from group activities when behavior was unacceptable, moving her to a quiet environment when verbally abusive, administering medications as ordered, assessing whether behavior endangered herself or others, avoiding power struggles and overstimulation, obtaining psychiatric consults, and offering preferred music when upset. However, this care plan contained no updates or revisions to address new or escalating aggression following three specific aggressive incidents on 03/01/26, 03/05/26, and 03/10/26.

On 03/01/26, a progress note by RN A documented that Resident #1 suddenly stood up in the dining room, ran toward Resident #2, and pulled her hair while Resident #2 was walking in front of her. Staff separated the residents, and head-to-toe assessments revealed no injuries, though Resident #2 screamed loudly in what staff believed was pain from having her hair pulled. On 03/05/26, a progress note by LVN B recorded that Resident #1 was observed yelling at Resident #3; before LVN B could reach them, she witnessed Resident #1 scratch Resident #3’s face, resulting in redness without skin break. Resident #3 was angry and agitated for about forty minutes following the incident, and the redness remained for about 24 hours. On 03/10/26, a progress note by RN B described Resident #1, without provocation, grabbing Resident #4 by the throat, pulling her hair, and verbally threatening her with profane language. The residents were separated, and no injuries were documented for Resident #4. These three episodes of aggression toward different residents occurred despite an existing behavioral care plan, and there is no indication in the care plan that it was revised or expanded to address these specific behaviors or patterns.

Additional record reviews and interviews confirmed that the care plans for the other involved residents did not identify new behavioral symptoms related to these incidents. Resident #2’s care plan listed behavioral symptoms including physical aggression and sexually inappropriate behaviors, with the last behavior dated months earlier, and did not reflect new issues arising from being the target of hair pulling. Resident #3’s care plan noted a history of aggression with the last incident dated 10/24/25, and Resident #4’s care plan identified wandering but no verbal or physical aggression or other behavioral symptoms. Observations on 03/24/26 showed Residents #2, #3, and #4 without obvious signs of abuse, neglect, bruises, or injuries, and family interviews for Residents #2 and #4 indicated no observed trauma or behavioral changes after the incidents. The DON, interviewed on 03/24/26, stated that the comprehensive care plan is updated by herself and assistant directors of nursing for acute incidents and acknowledged that failing to update interventions in Resident #1’s care plan would be a risk because the care plan is a way to communicate the plan of care to anyone providing care. Despite this, the documentation showed no revisions to Resident #1’s behavioral care plan after the three aggressive episodes, constituting the cited failure to develop and implement a comprehensive person-centered care plan consistent with resident rights and identified needs.