Failure to Care Plan for Resident’s Repetitive Foot-Dangling Behavior and Resulting Toe Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete care plan with measurable interventions to address a resident’s behavior of dangling her feet outside the bed and striking hard surfaces. The resident had a BIMS score of 11, indicating mild cognitive impairment, and had difficulty recalling the day of the week and communicating without prompting. The MDS also documented a diagnosis of seizure disorder or epilepsy. A Change in Condition Evaluation (COC) dated 2/13/26 documented that the resident often dangled her feet outside the bed and at times hit the hard parts of the bed and a nearby table, causing damage to her skin and nails. On that same date, CNA 1 reported a complete nail avulsion of the resident’s right great toe, described as dry and red in appearance, and the resident was aphasic and unable to describe what had happened. On observation on 2/19/26, the resident was seen lying in bed with the bed in a low position and a dressing on the right great toe; her feet were close to the footboard, and there were no devices in place to prevent her feet from hitting the footboard. CNA 1 stated she found the resident’s right great toenail off and did not know how it occurred. LVN 1 reported that CNA 1 informed him of the toenail avulsion, that other nurses also did not know how it happened, and that he assumed it may have been related to the resident dangling her feet outside the bed. During record review with LVN 1 and the DON, the COC and the care plan for the right great toenail avulsion were reviewed, and the DON acknowledged there was an assumption that the resident sometimes hit her leg on hard parts of the bed. The DON further stated that the interdisciplinary team had not addressed the resident’s behavior of dangling her feet outside the bed and hitting her legs on hard parts of the bed with care plan interventions.
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