Failure to Care Plan for Suctioning in Resident with Dysphagia and Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with significant medical needs. The resident was admitted with diagnoses including dysphagia, cerebral infarction, and unspecified convulsions, and had a BIMS score of 3, indicating severe cognitive impairment. The resident experienced episodes of coughing or choking during meals or when taking medications. Physician's orders dated 08/08/2025 indicated that oral suctioning may be performed for this resident. However, review of the resident's care plan showed that suctioning was not included as an intervention. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have been care planned for suctioning but was not.