F0656

D

Failure to Update Care Plan for Resident Eating Non-Food Items

Seguin, Texas Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and time frames to meet a resident's identified needs. The resident was an elderly female with dementia, need for assistance with personal care, mild protein calorie malnutrition, dysphagia, and major depressive disorder. A quarterly MDS showed moderate cognitive impairment with a BIMS score of 8/15. A Comprehensive Encounter note dated 02/17/2026, authored by a nurse practitioner, documented that a family member reported the resident had been trying to eat non-food items such as pennies and curtain hooks. Despite this documented behavior, review of the resident's undated care plan showed no mention of attempts to eat non-food items.

Certified nursing assistants reported in interviews that they were aware the resident would eat non-food items and that they needed to keep a closer watch on her, but they learned this information from other staff and were unsure if it was included in the care plan. They stated they typically relied on the care plan and verbal shift reports to know how to care for residents. The DON stated in an interview that he had not been made aware that the resident was trying to eat non-food items. The administrator acknowledged that the resident's attempts to eat non-food objects could be added to the care plan. Observation of the resident showed confusion and inability to respond appropriately to interview questions, with no observed attempts to eat non-food items at that time. The facility's policy on Care Plan Revisions Upon Status Change required that the comprehensive care plan be reviewed and revised as necessary when a resident experiences a status change, but the care plan had not been updated to address the resident's behavior of attempting to eat non-food items.