F0656

D

Failure to Develop and Implement Behavior Care Plans for Residents With Cognitive Impairment

Goshen, New York Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, measurable behavior care plans for residents with severe cognitive impairment and documented behavioral symptoms. Facility policy required that a comprehensive care plan, including measurable goals and timetables, be developed within seven days after completion of the comprehensive assessment to address medical, nursing, mental, and psychosocial needs. Despite this, for two residents with Alzheimer’s disease, encephalopathy, and other conditions, there was no behavior care plan documented in the electronic medical record, even though both had repeated episodes of wandering, resistance to care, and verbal and physical aggression documented by CNAs and in nursing progress notes.

One resident with Alzheimer’s disease, type 2 diabetes, and difficulty walking had an annual MDS showing severe cognitive impairment with inattention, disorganized thinking, delusions, and wandering. CNA documentation over a one‑month period showed frequent wandering and resistance to care across all shifts, and nursing progress notes recorded wandering and aggression on multiple dates, including an episode of confusion and agitation where the resident was fixated on missing belongings and past employment, requiring repeated phone calls to the spouse and 30‑minute visual checks. However, review of the resident’s care plans revealed no behavior care plan and no documentation in the ADL care plan that the resident was resistive to care. During interviews, a CNA and an LPN described the resident as confused, wandering, sundowning, repetitive, physically aggressive, and often refusing care, while the Unit Manager stated the resident did not have behaviors and acknowledged that no behavior care plan had been initiated.

Another resident with encephalopathy, syncope and collapse, and difficulty walking had an admission MDS indicating severe cognitive impairment with inattention and disorganized thinking. Although initially documented as having no behaviors, subsequent CNA documentation over several days showed wandering, verbally and physically abusive behavior, socially inappropriate or disruptive behavior, and resistance to care on multiple shifts. Nursing progress notes also documented frequent attempts to leave the unit and episodes of verbal and physical aggression during morning care. The resident had an elopement risk order and a potential for elopement care plan with interventions such as structured activities, identification, 15‑minute visual checks, and a WanderGuard device, but there was no documented evidence of a separate behavior care plan in the electronic medical record. The Unit Manager explained that behavior care plans should be developed for combative or physically/verbally aggressive residents and confirmed that care plans are to be initiated and updated timely, but acknowledged that a behavior care plan had not been created for this resident.