F0689

D

Failure to Provide Required Supervision for Resident With PICA Behaviors

Herrin, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accident hazards related to a resident with known PICA behaviors. The resident was admitted with diagnoses including brief psychotic disorder, other specified eating disorder, delusional disorders, depression, malnutrition, and a psychotic disorder, and had a BIMS score of 3 indicating severe cognitive impairment. The care plan identified the resident as requiring 1:1 supervision due to PICA, with documented behaviors of eating cigarette butts, plastic, Styrofoam, and pages from books, and noted that the resident was a current smoker needing supervision due to unsafe smoking habits. Despite this, the resident was placed on 15‑minute safety checks instead of 1:1 supervision for a period, based on management’s belief that she was not exhibiting PICA behaviors during that time.

Behavior tracking documentation from September through December showed repeated entries indicating the resident attempted to ingest non‑food items on numerous dates, but there were no corresponding narrative notes specifying what items were involved or describing the behaviors. Staff interviews revealed that when CNAs marked “yes” for putting non‑food items in the mouth, it meant the behavior was occurring and that the resident would put anything she could get her hands on into her mouth, including hair, hair ties, cigarettes, paper towels, and toilet paper. A CNA stated that when behavior tracking is triggered, a box appears to type in what the behavior is, and that she tries to enter a note, but also reported that no one asks follow‑up questions about the behavior tracking. The DON stated she reviews behavior tracking and progress notes every 72 hours and that the resident was not on 1:1 supervision during the identified period because she believed the resident was not having PICA behaviors.

Progress notes documented specific incidents during the same timeframe that demonstrated ongoing PICA‑related behaviors. On one date, the resident had three loose stools and was reported to have put the stool in her mouth each time. On another date, the resident was found rummaging through a desk drawer behind the nurse’s station, where she found a package of cigarettes and took a bite out of one before staff intervened. A later note recorded that the resident was inappropriately handling her own bowel movement during a bed check. The NP stated she had not been informed of the resident’s PICA behaviors or feces ingestion until December and that she would have initiated 1:1 supervision as a first intervention if she had been notified. The facility’s Behavior Management Policy required increased observation per the plan of care and the use of behavior tracking forms on all shifts so occurrences could be tabulated and analyzed, but the documented behaviors and staff statements showed that the resident’s ongoing PICA behaviors were not effectively communicated or acted upon to maintain the prescribed level of supervision.