Failure to Develop and Implement Care Plan for Resident's Disrobing Behavior
Penalty
Summary
The facility failed to develop and implement an individualized, resident-centered care plan for a resident who exhibited the behavior of pulling off her clothes or facility gown. The resident, who was admitted with diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and a gastrostomy, had a severe cognitive impairment as indicated by a BIMS score of 0. Multiple observations revealed the resident was frequently found half naked in her bed, with her upper chest exposed, and her privacy curtain only partially drawn, making her visible to others in the room. Interviews with staff, including a CNA, social services, RN, and the DON, confirmed that the resident had a known behavior of stripping off her gown and that there was no care plan in place to address this behavior. Staff acknowledged the need for frequent checks, especially when family was not present, but no formal interventions or strategies had been documented or implemented. Review of facility policy indicated that the interdisciplinary team is responsible for developing comprehensive, person-centered care plans, but this process was not followed for the resident's specific behavioral needs.