Failure to Develop Comprehensive Care Plan for Tube-Pulling Behaviors
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive care plan addressing a resident's behavior of removing hand mittens and pulling on their tracheostomy and gastrostomy (g-tube) tubes. The resident, who had diagnoses including respiratory failure, ventilator dependence, type II diabetes mellitus, and anxiety, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living. Nursing notes documented the use of bilateral hand mittens to prevent the resident from pulling out their tracheostomy and g-tube, and there was a documented incident where the g-tube became dislodged after the resident pulled on it, requiring replacement. Despite these documented behaviors and interventions, a review of the resident's care plan revealed that it did not address the behavior of removing mittens or pulling on the tracheostomy and g-tube. Staff interviews confirmed the ongoing issue, with reports of the resident removing mittens multiple times in a shift and the need for frequent reapplication. The facility's policy required a comprehensive, resident-centered care plan with measurable objectives and timeframes for all identified needs, but this was not implemented for the resident's specific behaviors.