Failure to Develop and Implement Care Plan for Spitting Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavior of spitting. The resident, who was admitted with diagnoses including diabetes mellitus, hyperlipidemia, dementia, and dysphagia, was found to have severely impaired cognition and was dependent on staff for most activities of daily living. Despite a long history of spitting, as reported by a Certified Nursing Attendant (CNA), there was no care plan in place to address this behavior. The CNA described providing the resident with a small trash can and reminders to spit into it, but these interventions were not documented in a formal care plan. During interviews and record reviews, the Director of Nursing (DON) confirmed being unaware of the resident's spitting episodes and acknowledged the absence of a care plan for this behavior. The facility's policy requires a comprehensive, resident-centered care plan to be developed for each resident, including measurable objectives and timeframes based on identified needs. However, the care plan for this resident did not address the spitting behavior, resulting in a failure to deliver necessary care and services as outlined in the facility's own procedures.