F0880

E

Failure to Implement Infection Control Measures for Resident With Feces-Smearing Behavior

Pasadena, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program for a resident with known feces-smearing behavior. The resident was an adult male with schizoaffective disorder, bipolar disorder, depressive type, GERD, bowel and bladder incontinence, social isolation, and a PASRR Level II for serious mental illness. His MDS showed moderate cognitive impairment and a need for assistance with toileting. The care plan identified a focus on behaviors of eating or smearing feces, with goals and interventions related to monitoring behaviors, explaining procedures, encouraging activities, and reporting changes to the MD. Despite this, multiple episodes occurred in which the resident had feces on his hands, under his fingernails, on his face, beard, sides of his mouth, teeth, and pillow, and in or around his mouth, without consistent reporting or documentation to nursing or leadership.

On one occasion, a medication aide who was also a CNA observed the resident during a medication pass placing his hand into his adult brief, pulling out feces, and attempting to put his soiled hand into his mouth. She intervened, cleaned the resident, changed his brief, and repositioned him, but did not document or report the incident to the charge nurse, assuming the behavior had already been reported. In another incident, a PTA entered the resident’s room around lunchtime and observed soiled hands, a fecal odor, and a brown tinge in the resident’s mustache, beard, chin, and teeth, with fecal odor from the resident’s mouth. The PTA cleaned the resident’s hands and fingernails, reported the situation to an LVN and to the Director of Rehabilitation, but there is no indication that this episode was documented in the medical record or that it was reported up the nursing chain as a change in condition.

An anonymous source reported that the resident was known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth on a recurring basis, and that a non-direct care male staff member had notified an LVN after seeing feces on the resident’s hand. According to this account, the LVN entered the room, observed the condition, stated she was not dealing with it, and left the resident as he was, after which the male staff washed the resident’s hands but could not complete full cleaning due to other duties. The LVN later stated she had been called to the room by the PTA, saw what she thought was dried chocolate on the resident’s hands, mouth, and pillow, and only later realized it was feces when the resident identified it as “poop.” She stated she called an aide to clean the resident but did not notify the resident’s nurse or MD, assuming the information had already been relayed, and believed she had documented the incident, though no such documentation was confirmed in the report. The resident himself reported episodes of diarrhea, digging in his brief, finding feces on his hands and under his fingernails, and then unknowingly rubbing his face and beard, sometimes getting feces into or around his mouth, and stated he relied on staff to clean him and change his brief and sheets afterward.

Nursing leadership, including the ADM and DON, reported initially being unaware of the resident’s behavior of digging in his brief and getting feces on his hands and mouth, and the resident’s primary nurse (an LVN) stated she had not been informed of any such episodes. The ADON, who served as the infection preventionist, stated she was informed that the resident had smeared feces but only later learned that feces had been in his mouth and beard. The MDS nurse reported she care planned for feces smearing once informed but would have escalated to an IDT meeting and broader notifications had she known feces were in and around the resident’s mouth. The facility’s written infection control policy required a comprehensive infection control program with surveillance, reporting, education, and QAPI oversight, but the repeated failure of multiple staff (including an LVN, a medication aide/CNA, and a PTA) to consistently recognize, document, and report these feces-related incidents to the resident’s nurse and leadership led to the cited deficiency in infection prevention and control.

Additionally, the resident had an active order for PRN ondansetron for nausea and vomiting, but the MAR for December and January showed no doses administered as of early January, despite the resident’s report of diarrhea and the NP and MD notes documenting loose stools and diarrhea. The MD ordered labs to monitor for dehydration and electrolyte imbalance, and the NP documented a chief complaint of diarrhea, but there was no documentation of ondansetron use. While the primary deficiency centers on infection control, these clinical details underscore that the resident was experiencing ongoing gastrointestinal symptoms at the time the feces-smearing and oral contamination behaviors were occurring, and that staff were aware of his diarrhea and incontinence but did not consistently integrate this information into infection control surveillance and reporting as required by the facility’s infection control program.