Failure to Update Care Plan for Cognitively Impaired Resident’s Bedtime Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update and implement an adequate care plan addressing a cognitively impaired resident’s behaviors related to going to bed and remaining in bed. The resident was admitted with Alzheimer’s disease with late onset, dementia, COPD, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and low BMI, and was documented on the MDS as severely impaired in decision-making. The care plan identified impaired cognitive function/dementia and behavior problems with agitation, including physical and verbal aggression and rejection of care, with interventions such as offering to return later, calling family, and redirecting the resident. The resident was also care planned as at risk for falls with interventions including ensuring the call light was within reach, use of a nontraditional call light in a recliner, and a directive that when in a wheeled recliner the resident should be out of her room. However, the care plan did not include any focus area or interventions specifically addressing the resident’s behaviors around going to bed, methods to get her to go or stay in bed, or what to do if she refused. Surveyor observations and staff interviews showed that the resident’s actual needs and staff practices were not reflected in the written care plan. On one evening, the resident was observed asleep in a wheeled recliner at the nurses’ station, then taken to her room by a CNA and shortly thereafter brought back to the nurses’ station after refusing to go to bed. Multiple CNAs stated they did not think the resident could use a call light appropriately, and the care plan coordinator acknowledged not knowing if the resident could use a call light, while also stating that if the resident was in her recliner she was not to be left unattended and should be brought to the nurses’ station. The DON reported that the team had discussed strategies such as putting the resident to bed when she appeared tired, calling her daughter if she became agitated, and returning her to the nurses’ station if she remained agitated, but also stated this information should be on the care plan and that the resident could not cognitively use a call light or be left unattended in her room in the recliner. The resident’s family member reported not being called that night and expressed a desire for staff to make a real attempt to get the resident to lie down due to a pressure sore and prolonged sitting, while confirming the resident was not on medications for agitation. These facts demonstrate that the care plan was not updated to reflect known behavioral patterns, limitations in call light use, and agreed-upon approaches to bedtime care.
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