F0656

E

Failure to Update Person-Centered Care Plans for Behavioral Symptoms, Refusals, and Suicidal Ideation

San Antonio, Texas Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and update comprehensive, person-centered care plans with measurable objectives and time frames for multiple residents whose needs and behaviors had been identified through assessments, progress notes, and incidents. For one male resident with Alzheimer’s disease, cognitive communication deficit, impulse disorder, and major depressive disorder, the quarterly MDS showed moderate cognitive impairment. Task records for bathing over a 30‑day period documented that this resident accepted only two baths and refused eight, and the facility’s grievance log showed he complained of not being changed and not being showered. During interview, he denied refusing showers, while staff, including an LVN and the DON, stated he sometimes refused showers despite encouragement and that such refusals should be reflected in the care plan to respect his right to refuse and guide staff in offering and encouraging hygiene. However, his care plan contained no mention of shower refusals.

A second female resident with Alzheimer’s disease, anxiety disorder, depression, spastic hemiplegia, and severely impaired cognition was totally dependent for self‑care and mobility and used a manual wheelchair. Her admission MDS triggered care areas and documented cognitive loss/dementia, communication issues, falls, and psychotropic drug use, but did not include review or revision addressing psychosocial well‑being, behavioral symptoms directed toward others, or refusal of medications and care. Progress notes over several days documented repeated episodes of verbal and physical aggression toward staff during ADL care, including striking or attempting to hit, push, and grab staff, as well as multiple refusals of care, refusal of all medications, and refusal of weight checks. An incident report and progress notes also documented a resident‑to‑resident incident in which she slapped her roommate, after which the residents were separated and she was placed near the nurse’s station. Despite these documented behaviors and refusals, her care plan, dated and revised in February, addressed cognitive impairment, language barrier, and potential adverse effects of antidepressants but did not include revisions to reflect her aggressive behaviors, refusals, or related psychosocial needs.

A third female resident with Alzheimer’s disease, recurrent major depressive disorder, suicidal ideations, repeated falls, and cognitive communication deficit had severely impaired cognition but could perform some self‑care with help and used a manual wheelchair independently. Her care plan included problems and interventions for physical functioning deficits, physically abusive behavior (cursing, yelling, throwing items), potential adverse effects of antidepressants, impaired communication, dementia‑related complications, and refusal of care, with interventions such as room changes, documenting behaviors, obtaining antianxiety medication, identifying root causes of refusal, and using clear communication. However, following an incident in which she reportedly stated she was going to kill herself, nursing documentation described immediate safety assessment and her denial of suicidal ideation, and a psychiatric NP note described that she had been placed on 1:1 observation after the reported suicidal statement, denied current SI, and had her sertraline dose increased, with instructions to staff to report any return of suicidal thoughts. A psychology progress note later documented that she denied SI/HI/AVH. Despite these documented suicidal ideation symptoms and related psychiatric interventions, there was no review or revision of her care plan to address her psychosocial well‑being or suicidal ideation following the incident. Interviews with regional and facility leadership, including the Regional Nurse, MDS Coordinator, ADON, DON, Senior Director, and former ADM, confirmed that IDT meetings occurred and interventions were discussed and implemented for residents with behavioral issues and suicidal ideation, but acknowledged that the MDS assessments and care plans for these residents were not updated to reflect the documented behaviors, refusals, and psych service interventions, contrary to facility policies on comprehensive care plans, MDS completion, and abuse/neglect prevention that require ongoing assessment and care planning for residents with behaviors that might lead to conflict or neglect.