F0657

D

Failure to Update Care Plan for Resident Uncovering Behavior Affecting Dignity

Torrance, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to update the comprehensive care plan to address a resident’s behavior of uncovering themself, which was necessary to maintain the resident’s dignity and rights. The resident was admitted for rehabilitation with diagnoses including failure to thrive, a right renal mass, and chronic diastolic congestive heart failure, and was documented as alert and oriented with adequate insight and judgment. Subsequent documentation showed the resident had profound debility, required 24/7 assistance, and needed maximum assistance with feeding, grooming, dressing, bathing, transferring, and was 100% incontinent of bowel and bladder and unable to perform toileting. Staff, including the Assistant Nurse Manager, reported that the resident tended to uncover themself at times and acknowledged that interventions and care plan updates should have been in place for this behavior to maintain dignity.

The resident’s responsible party reported observing the resident’s private area from the waist down exposed to the public while standing in the hallway outside the resident’s room, and staff informed her that the facility was a “diaper-free clinic” to prevent skin and infection problems. A review of the care plan audit trail from late October through late February showed no updates or interventions addressing the resident’s uncovering behavior during the admission. The Regulatory Accreditation Program Manager confirmed that no intervention or care plan entry was found regarding the resident’s tendency to uncover themself. This was inconsistent with the facility’s policy requiring care plans to be initiated within 24 hours of admission and reviewed and updated whenever there is a new order, change of intervention, or when interventions become ineffective or not applicable.