Failure to Care Plan Resident’s Inappropriate and Disruptive Behaviors
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s inappropriate behaviors. The resident was an adult male with type 2 diabetes, major depressive disorder, heart disease, end stage renal disease, and dependence on renal dialysis, with an MDS BIMS score of 13 indicating intact cognition. The resident’s care plan, dated 01/30/26, did not include any problem, goals, or interventions related to inappropriate behaviors such as making rude or vulgar comments, taking facility or staff items, playing music loudly, or recording staff with his phone. Progress notes between 08/29/25 and 01/30/26 documented at least two behavior-related incidents: one where the resident used vulgar language and made sexually inappropriate comments to staff, and another where he removed furniture from other rooms and placed it in his own room, for which staff only provided education about safety. In interviews, the ADON and DON both confirmed that the resident had ongoing inappropriate behaviors, including making rude or sarcastic comments about staff bodies, taking staff meals and facility items (such as a nurse station chair) to his room, playing music loudly enough that other residents complained they could not sleep, and recording staff with his phone. The ADON stated staff verbally redirected the resident and asked him to use headphones at night, but she was unsure if these behaviors were care planned. The DON acknowledged that the behaviors were not included in the care plan, that staff only verbally redirected the resident, and that no other interventions were implemented. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timetables, and specified that assessments are ongoing and care plans are revised as resident information and conditions change, but this was not done for this resident’s behavioral issues.
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