F0740

D

Failure to Report and Care Plan Repetitive Feces-Ingestion Behavior in Psychiatric Resident

Pasadena, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary behavioral health care and services and to promptly notify the physician after significant changes in condition for a resident with serious mental illness. Resident #2, a male with diagnoses including schizoaffective disorder (depressive type), bipolar disorder, cognitive communication deficit, and GERD, had a PASRR Level II for serious mental illness and a BIMS score indicating moderate cognitive impairment. He required assistance with toileting and was incontinent of bowel and bladder. His care plan identified a PASRR-positive status and a risk for increased episodes and injury behaviors related to smearing feces, with goals for decreased behaviors through monitoring and interventions, but the care plan did not include focused behaviors related to digging in his brief, eating, or smearing feces.

Resident #2 reported during interview that he had experienced repeated days of diarrhea and, due to discomfort, sometimes dug in his soiled brief, after which feces would be on his hands and under his fingernails. He stated he had rubbed his face, beard, sides of his mouth, and possibly placed his soiled hands in his mouth, and that this behavior had been an ongoing habit. He indicated he was often unaware his hands were soiled until after he had already put them in his mouth and did not recall calling staff for assistance, though he stated staff would clean him once they discovered he was soiled. Progress notes showed that on one date a NP evaluated him for diarrhea and an MD ordered monitoring for dehydration and electrolyte imbalance with labs, but there was no documentation of episodes involving feces on his hands, face, or in his mouth.

Multiple staff interviews described specific incidents where Resident #2 was observed with feces on his hands, under his fingernails, on his face and beard, and in or around his mouth and teeth, which were not properly reported, documented, or communicated to his MD. A medication aide stated she saw the resident reach into his brief, pull out feces, and attempt to place his soiled hand into his mouth; she intervened, cleaned him, but did not document or report the incident, assuming it was already known and care planned. An anonymous person reported that around the New Year holiday, the resident had feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth, and that when an unknown male staff reported this to an LVN, the LVN allegedly refused to deal with it and left the room, with the incident going undocumented and without isolation or monitoring. The PTA reported entering the resident’s room and finding feces on his hands, in his facial hair, and in his mouth and teeth, with a fecal odor, and stated he notified an LVN and then personally cleaned the resident when no one returned; he also stated this was not the first such incident.

Further interviews showed that the resident’s primary nurse (LVN A) was not informed of these behaviors and stated she would have reported them as a change in condition to the DON, administrator, and MD had she known. LVN B recalled being asked by the PTA to look at what she initially thought was chocolate under the resident’s fingernails and around his mouth; she cleaned him and educated him about using the call light but did not recognize it as feces at the time and did not report it to the MD, though she acknowledged such an incident would be a change in condition requiring immediate reporting. The administrator and DON stated they were not aware of any issues reported to the MD regarding feces in or on the resident’s mouth and acknowledged the behavior was not reflected in the care plan. Facility policies required that the MD and DON be notified of changes in condition and that infection control protocols and standards of care be followed, but the episodes of feces on and in the resident’s mouth, hands, and facial hair were not consistently reported, documented, or incorporated into his behavioral health care planning, leading to the cited deficiency.