F0657

D

Failure to Update Care Plans for Behavioral 911 Calls and Ordered Helmet Use

Phoenix, Arizona Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect known behaviors and treatment needs for two residents. For the first resident, who had multiple sclerosis, bipolar disorder, anxiety disorder, and a cognitive communication deficit, the MDS documented moderate cognitive impairment and dependence on staff for multiple ADLs. A complaint was filed stating that this resident had called 911 to request a brief change and had a history of doing so. Staff interviews confirmed that the resident experienced anxiety and sundowning, frequently believed she had pressed the call light when she had actually pressed the bed remote, and then, in a panic, dialed 911 for assistance with brief changes. Despite this ongoing behavior, the resident’s care plan, initiated in early 2022 and revised over time, did not include the behavior of calling 911 for brief changes.

The acting DON stated that residents’ behaviors are always supposed to be documented in the care plan so clinical staff know what behaviors to expect. CNAs interviewed described the resident’s pattern of anxiety, confusion, and repeated 911 calls when she believed she had not received needed incontinence care, even though staff reported that brief changes were completed frequently. However, there was no evidence in the care plan that this behavior had been identified, addressed, or incorporated into the resident’s person-centered interventions, despite the facility’s own expectation that such behaviors be care planned.

For the second resident, who had epilepsy, traumatic brain injury with brain compression and herniation, alcoholic cirrhosis, thrombocytopenia, hypertension, unspecified dementia with moderate cognitive impairment, anxiety disorder, and mood disorders including depression, the care plan and orders required the resident to wear a helmet when out of bed. A care plan focus initiated in mid-2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included wearing a helmet out of bed. An active order entry and physician progress notes documented that the resident was to utilize a helmet when out of bed. There was no evidence in the care plan that the resident refused the helmet or that helmet use had been discontinued. Observations over multiple days showed the resident repeatedly out of bed, standing, walking in his room, in activities, and in the dining room without the helmet, even though a sign in the room initially stated “HELMET ON AT ALL TIMES OUT OF BED,” and the helmet was visible on the nightstand.

Nursing and CNA staff interviews revealed uncertainty about why the resident needed the helmet, whether the order was still active, and whether therapy had discontinued it. One LPN stated she had not seen the resident wear the helmet and was unaware of the order, and could not locate the helmet treatment on the MAR/TAR, even though she acknowledged that such an appliance should be documented there and that refusals should be recorded and communicated. A CNA reported that the resident used to wear the helmet more frequently but did not know why he stopped or why he should be wearing it, and had never been instructed to assist with or educate about helmet use. The director of rehabilitation confirmed that therapy had assessed and trained the resident and staff on helmet use, that the resident had been discharged from therapy with the expectation to continue helmet use out of bed, and that there was no documentation that the helmet had been discontinued.

The interim DON stated that the facility is expected to follow provider orders as written, that care plans must be updated quarterly and as needed, and that refusals of care should be documented and reflected in the care plan so providers can make necessary changes. When reviewing the resident’s care plan, the interim DON believed there was a note indicating the resident refused the helmet, but the care plan retrieved from the electronic health record did not contain such a note, and she was unsure about the documentation discrepancy. Facility policies on comprehensive person-centered care planning and documenting and charting required that refusals of services posing health and safety risks be identified in the care plan, including the declined care, associated risks, and the interdisciplinary team’s educational efforts, and that the medical record provide a complete account of care and treatment. For both residents, the survey findings showed that the care plans were not updated and revised to accurately reflect known behaviors and treatment orders, leading to incomplete and inconsistent documentation of their current care needs and interventions.