Failure to Update Care Plan for Resident's Ingestion of Fecal Material
Penalty
Summary
Facility staff failed to review or revise the comprehensive care plan for one resident to address behaviors involving playing with and ingesting fecal material. The resident, who was admitted with diagnoses including bipolar disorder and dementia, was assessed as severely cognitively impaired according to the most recent MDS. Despite documentation in a psychiatric note and multiple staff observations of the resident engaging in these behaviors, the care plan dated several months after these incidents did not include interventions or strategies to address them. Interviews with CNAs and an LPN confirmed that the resident frequently removed and ingested feces, even after being toileted, and that staff were not aware of any specific plan to prevent or manage this behavior. The LPN, after reviewing the care plan, acknowledged that it did not address the resident's behavior. Administrative staff were informed of these findings, and no additional information was provided prior to the survey exit.