This 34-year-old male resident with a history of Autism Spectrum Disorder, moderate Intellectual and Developmental Disability, seizure disorder, PICA, and Gastroesophageal Reflux Disease was monitored for the 0700-1500 shift.
Neurological: Resident is alert. Seizure precautions remain in place at the bedside. No seizure activity was observed this shift. Behavior was calm throughout the morning. At approximately 1400, resident became agitated, evidenced by pacing and loud vocalizations, following a change in the program schedule. There was no self-injurious behavior noted. Staff successfully redirected resident to a quiet room with a weighted blanket for de-escalation. Behavior returned to baseline by 1430. No aggression was exhibited toward staff or peers.
Safety: At 1100, resident attempted to mouth a small plastic piece during an activity. Staff intervened promptly to remove the object, and no ingestion occurred. Resident was redirected. Per the Behavior Support Plan, 1-to-1 supervision was reinforced during activities. No injuries, incidents, or use of restraints occurred this shift.
Gastrointestinal/Nutrition: All morning medications were administered as per the Medication Administration Record at approximately 0800 without refusal. Appetite was good, with 100% of breakfast and 90% of lunch consumed. Resident had one loose bowel movement at 1230. Bowel protocol is active; resident is being monitored as the last documented bowel movement was two days prior.
Vital Signs (1000): Blood Pressure: 128/78 mmHg, Heart Rate: 78 bpm, Temperature: 98.2°F, Respiratory Rate: 18/min, SpO2: 98% on room air.
Activity/Musculoskeletal: Resident had a Physical Therapy visit at 1000 and ambulated 50 feet in the hallway with a rolling walker, which was tolerated well. Participated in the afternoon music group, where he was engaged and calm.
Integumentary: Skin check performed. No new areas of breakdown noted. The existing Stage 1 pressure injury on the coccyx is unchanged. Barrier cream was applied.
Family Communication: Resident's sister called at 1330 for an update. Update provided, no concerns were expressed.