F0656

D

Failure to Care Plan for Resident’s Recurrent Public Disrobing Behaviors

Dwight, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop a complete care plan with problem, goals, and measurable interventions to address a resident’s ongoing behaviors of public disrobing. The resident had a Minimum Data Set documenting severe cognitive impairment and behavior tracking that showed repeated disrobing episodes over a one‑month period, including multiple dates where the resident removed clothing or partially disrobed. Nursing documentation noted increased confusion with hallucinations and an incident where the resident removed her gown and had her incontinence brief halfway off while sitting in the hallway, requiring staff assistance with dressing.

Despite these documented behaviors, the resident’s care plan, revised on a specified date, only addressed wandering into other residents’ rooms and an incident of pulling her top up in a male resident’s room, and did not include a specific problem, goals, and interventions for public disrobing. An abuse investigation report and CNA interview documented an event where the resident was in another resident’s room holding up her gown while the other resident touched her breast. The DON stated that the resident was not aware of her surroundings and would change her gown in the hallway or come out of her room while putting her top on, and confirmed that this was not a new behavior and that the care plan did not include a problem, goal, and interventions to address the resident’s public disrobing behaviors. The facility’s Abuse Prevention and Reporting policy required staff to identify residents with needs, triggers, and behaviors that might lead to conflict and to care plan problems, goals, and interventions to reduce chances of abuse, which was not done in this case.