F0561

D

Failure to Update Care Plan to Reflect Resident and Family Preferences Regarding Room Access and Privacy

Madisonville, Texas Survey Completed on 03-03-2026

Penalty

Fine: $16,065

Summary

The deficiency involves the facility’s failure to honor a resident’s right to make choices about significant aspects of her life and to reflect those choices and family wishes in her comprehensive care plan. The resident was admitted with multiple diagnoses including cerebral infarction, dementia, generalized muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, and major depressive disorder. Her Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment, and she was care planned for communication problems, impaired cognitive function/dementia, impaired thought processes, and risk for wandering. However, the care plan contained no interventions or notes addressing redirecting her from male residents’ rooms, despite staff knowledge of family concerns about her being alone with a male resident.

Psychosocial and psychological evaluations documented mixed information about the resident’s cognition. A psychosocial evaluation indicated functionally intact cognition, full orientation, intact memory, adequate judgment, and circumstantial/confusing thought processes, while a psychological progress note described her as awake, alert, oriented times three, with logical and coherent thought processes and no acute concerns regarding memory or cognition during that session. In an interview, the resident stated that staff would not allow her and a male resident to be alone in each other’s rooms, reported that staff told her the male resident would get her pregnant and that her family had an issue with her being alone with him, and stated she felt alert, oriented, and able to consent or refuse. She also reported that neither she nor her family had concerns about her having privacy time alone with the male resident and that she felt rotten, down, and upset because staff did not allow them privacy and she had no privacy from staff.

Multiple staff interviews revealed that the resident’s family had expressed, on unknown dates, that they did not want the male resident alone in the room with her and did not want her going into any male residents’ rooms, citing concerns about her capacity to consent and fluctuating cognition. The MDS nurse, SW, ADON, DON, and ADM all acknowledged that the IDT process and care plans are used to reflect resident and family preferences and guide staff in providing care, and that care plans should be revised when such preferences are communicated. Despite this, the MDS nurse did not revise the resident’s care plan to include interventions to redirect her from male residents’ rooms, and the DON later stated she did not know the care plan had not been updated to reflect these preferences and choices. The facility’s Comprehensive Care Planning policy states that each resident will have a person-centered care plan developed and implemented to meet preferences and goals, and that changing preferences and goals should be reflected in the care plan, but this was not done for this resident.