F0656

D

Failure to Care Plan Mattress Use and Crawling Behavior for Cognitively Impaired Resident

Navasota, Texas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and timeframes that reflected a resident’s identified needs and behaviors. The resident was an elderly male with Alzheimer’s disease with late onset, abnormalities of gait and mobility, bipolar disorder with severe depressive episode and psychotic features, generalized muscle weakness, and a prior cerebral infarction. His Quarterly MDS showed he was unable to complete the BIMS, had poor short- and long-term memory, severely impaired decision-making, difficulty focusing, and disorganized thinking. He required at least supervision or touching assistance for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers. Despite these needs and cognitive impairments, his Comprehensive Care Plan dated 01/19/2026 and revised on 02/05/2026 did not include that he had a mattress beside his bed, that he lay on this mattress, or that he crawled off the mattress toward his roommate’s bed.

Nursing documentation showed repeated observations of the resident lying on a mattress on the floor next to his bed and engaging in crawling behavior toward his roommate’s bed, but these observations were not incorporated into the care plan. Nurse notes on 01/31/2026 at multiple times documented the resident lying on a mattress on the floor parallel to his bed. Additional nurse notes on 02/02/2026 documented that the resident was not staying on the mattress, crawled off it twice, and was observed crawling toward his roommate’s bed, and later that he rolled off the mattress onto the floor and toward the roommate’s bed, awakening the roommate. None of these behaviors or the use of the mattress on the floor were reflected in the resident’s care plan, and therefore were not communicated through the care plan to guide staff interventions.

Interviews with facility staff confirmed that the behavior and mattress use should have been care planned and that the care plan is the source of information for the CNA Kardex. The MDS Coordinator stated that if a resident had a mattress beside the bed and was crawling off it toward a roommate’s bed, this behavior was expected to be care planned, and acknowledged that the care plan is used to inform staff how to provide needed care and interventions. The DON and Administrator both stated their expectation that such a mattress and related behaviors be included on the care plan, and that CNA Kardex information comes from the care plan. A CNA/MA reported that the resident had a mattress on the floor by his bed for approximately two weeks before he died, that he preferred lying on the mattress, and that he began to crawl toward his roommate’s bed, but she did not recall seeing this on the Kardex. An LVN reported she had not been trained on how to document or revise care plans despite working at the facility for over a year, while another LVN stated she had been trained at a different facility owned by the same company. The Nurse Consultant stated all nursing staff had been in-serviced on documenting care plans but could not provide dates or documentation of such training. The facility’s written policy stated that care plans would be reviewed and revised based on changing goals, preferences, and needs, but the resident’s mattress use and crawling behavior were not added to the care plan despite repeated documentation in the nurse notes.