F0657

D

Failure to Revise Care Plans for G-Tube Management and Recurrent Falls

Providence, Rhode Island Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents’ care plans were revised by the interdisciplinary team to reflect current physician orders and changes in condition, specifically related to a gastrostomy tube (g-tube) and recurrent falls. One resident with a history of a cerebrovascular accident, muscle weakness, and a g-tube had physician orders dated 9/4/2025 to encourage use of an abdominal binder at all times on every shift, and a subsequent order dated 1/7/2026 specifying that the resident was to wear the abdominal binder, with removal allowed only during ADL care or showering. The resident’s care plan, which included a focus area initiated on 6/24/2025 for behavior problems of tactile impulses (including pulling the g-tube), was last revised on 8/26/2025 and did not include the abdominal binder as an intervention. During an interview, the DNS acknowledged that the care plan was not revised to include the abdominal binder.

The deficiency also includes failure to revise care plans in response to multiple falls for two residents. One resident experienced multiple falls on several dates in December 2025 and January 2026. Although this resident had a care plan focus area initiated on 2/3/2025 for frequent falls secondary to generalized weakness, decreased neuromuscular coordination, and cognitive impairment, the last revision was on 12/2/2025 and did not include added interventions related to the subsequent falls. The DNS was unable to provide evidence that the care plan was updated following these events. Another resident, admitted with dementia and unsteadiness on feet, sustained multiple falls in December 2025. Review of this resident’s care plan failed to show any focus area for falls, and the DNS could not provide evidence that the care plan was revised to address falls.