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F0656
D

Failure to Develop Disease-Specific Care Plan for Resident with Huntington's Disease

Saint Charles, Missouri Survey Completed on 06-23-2025

Penalty

Fine: $97,580
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with Huntington's disease, traumatic subdural hemorrhage, and anxiety. The care plans in place addressed some behavioral symptoms, activities of daily living (ADLs), and communication challenges, but none were specific to the unique symptoms and care needs associated with Huntington's disease. The care plans lacked detailed interventions to address the resident's neurodegenerative condition, including the progressive cognitive decline, mood disturbances, and involuntary movements characteristic of Huntington's disease. Observations, interviews, and record reviews revealed that staff were not adequately informed or trained about Huntington's disease and its impact on the resident. Multiple staff members, including a Certified Medication Technician and housekeeping staff, expressed fear of the resident and admitted to not knowing what Huntington's disease was or how to approach or communicate with the resident. The resident reported that staff did not listen or understand that certain behaviors, such as spilling things, were due to the disease and not intentional actions. Family members and staff interviews further indicated that the lack of disease-specific care planning led to misunderstandings and inadequate care. Family observed that staff did not communicate effectively with the resident, often entering the room without explanation or knocking, and misinterpreted the resident's behaviors as intentional aggression rather than symptoms of the disease. The Registered Nurse responsible for care planning acknowledged the absence of a care plan specific to Huntington's disease, and the Administrator confirmed the expectation that such plans should be in place to guide staff and ensure appropriate care.

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