Failure to Address Crawling Behavior in Resident Care Plan
Penalty
Summary
The facility failed to update and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting the resident's behavior of crawling on the floor. Despite multiple assessments and staff observations indicating that the resident had a history of confusion, impaired cognition, decreased coordination, and required extensive assistance with mobility and activities of daily living, the care plan only addressed general fall risk interventions such as floor mats and call light accessibility. The care plan did not include specific interventions or goals related to the resident's repeated behavior of crawling on the floor, which was observed and reported by both staff and another resident as occurring multiple times daily, including instances where the resident crawled into the hallway and attempted to pull himself up using hallway rails. Interviews with staff, including a CNA and LVN, confirmed that the resident frequently crawled out of bed and onto the floor, requiring staff assistance to return him to bed or his wheelchair. The DON acknowledged that the care plan should have been updated to reflect this behavior, in accordance with facility policy, but it was not. As a result, there were no nursing interventions in place to address the resident's crawling behavior, which was a significant omission given the resident's cognitive and physical impairments.