Failure to Care Plan for Resident’s Known Oral-Seeking Behavior and Supervision Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan addressing a developmentally delayed resident’s known behavior of placing objects in the mouth, associated choking risks, and required level of supervision. The facility’s admission assessment policy required initial and ongoing assessments to obtain information necessary to develop and maintain an individualized interdisciplinary plan of care. Despite this, review of the resident’s comprehensive care plans showed no documentation of the resident’s oral-seeking behavior, the risk of choking related to this behavior, or the specific level of staff supervision needed to maintain safety. The resident, admitted in 2016 with mitochondrial disorder, developmental and intellectual delay, and hypotonia, was well known to multiple staff as being “very sensory seeking” and frequently gumming or putting items, including toys and fingers, in the mouth. On the date of the incident, the resident was seated in a common room playing with a battery-powered doll when staff requested emergent assessment from the NP due to concerns for choking/gagging and possible AA battery ingestion. The toy’s rear Velcro pouch was found open, the battery pack cap was off, and one of two AA batteries was missing; a search of the resident and environment did not locate the missing battery. Hospital records confirmed a battery in the resident’s abdomen, which was removed via endoscopy. Subsequent surveyor observations documented the resident in a classroom with a toy rubber ring in the mouth and later in a common room with a toy rubber carrot in the mouth. Interviews with the MDS nurse, NP, CNA, and ADON confirmed that the resident routinely put items in the mouth and that the resident had always required direct supervision when in a wheelchair, yet the MDS department did not typically include supervision levels or specific behaviors in the comprehensive care plan, and these needs were not reflected in the resident’s plan of care.
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