Failure to Follow Care Plan for Monitoring Paranoid Delusions Leading to Aggressive Incident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow a resident’s care plan interventions for monitoring paranoid delusions. The resident, who had diagnoses including major depressive disorder, HTN, and CKD, was assessed on the MDS as having moderate cognitive impairment and needing staff assistance with toileting, eating supervision, and personal hygiene. The resident’s care plan dated 3/12/2026 documented episodes of paranoid behavior, including claims that the mafia was trying to kill him, and included an intervention to monitor episodes of paranoid delusions every shift. However, review of the medical record showed there was no physician order for behavior monitoring of paranoid delusions, and no behavior monitoring tasks were created in the MAR, where such monitoring was supposed to be documented when an order existed. During an interview, the resident reported that on 3/2/2026, while eating dinner in the dining hall, he believed another resident was talking about him on the phone after reading the other resident’s lips, and he responded by walking up and punching the other resident in the face. RN 1 stated that monitoring the resident’s paranoid delusions every shift was important to ensure the effectiveness of the medication regimen and to determine the need for physician reassessment, and acknowledged that monitoring tasks are generated only when there is an order. The DON stated that following the care plan is important to prevent unaddressed aggressive behaviors and to keep residents and staff safe, and that monitoring paranoid delusions allows evaluation of the effectiveness of the current plan of care and the need for physician reassessment or medication adjustment. The facility’s comprehensive, person-centered care plan policy indicated that services outlined in the care plan are to be provided by qualified persons to help attain or maintain the resident’s highest practicable well-being.
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