Failure to Implement Care Plan Wellness Checks After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident following a reported verbal altercation with her daughter. On 2/21/26 at 6:54 p.m., an SBAR (Situation, Background, Appearance, Review and report) communication form and progress note documented that a CNA reported verbal abuse from the resident’s daughter after overhearing an argument from the resident’s room during meal pass. In response, the resident’s care plan, dated 2/23/26, identified an alteration in well-being related to the verbal altercation between the resident and her daughter and included an intervention for the Social Service Designee to conduct wellness checks for 72 hours. During a concurrent interview and record review on 3/5/26 at 11:35 a.m., the Social Service Director was unable to provide documentation that the wellness checks had been completed for the resident. In separate interviews on 3/5/26, both the Administrator and the DON stated that Social Services should have monitored the resident and completed the 72-hour wellness checks after the incident. Review of the facility’s Comprehensive Care Plans policy dated 11/2017 indicated that the comprehensive care plan should be updated to reflect changes in condition and that interventions are instructions to disciplines to perform direct care or provide assistance so residents may strive to achieve their established goals. Despite the care plan intervention specifying wellness checks, there was no documented evidence that these checks were carried out.
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