Failure to Obtain Psychiatric Referral for Dementia Resident
Summary
The facility failed to obtain a psychiatric referral as ordered for a resident diagnosed with dementia who exhibited signs of psychosis. The resident, who had a history of severe cognitive impairment and behavioral disturbances, was admitted to the facility following a hospitalization where he had been physically restrained and started on antipsychotic medication. Despite multiple instances of severe agitation, paranoia, and hallucinations, the facility did not ensure that the resident received the necessary psychiatric evaluation and services as ordered by the physician. The resident's medical records and physician notes indicated ongoing issues with agitation, paranoia, and psychotic episodes, including suicidal ideations and aggressive behavior towards staff and other residents. The facility's Director of Nursing noted the need for a psychiatric referral, but the referral was not completed due to the resident's initial refusal. Subsequent physician notes continued to document the resident's severe agitation and psychosis, yet no psychiatric consult was obtained. The resident's condition escalated, leading to multiple incidents of aggressive behavior, including an altercation with another resident. Despite the physician's repeated recommendations for a psychiatric referral, the facility failed to follow through, resulting in the resident being hospitalized after a severe episode of aggression. The facility's Social Services Director later confirmed that the psychiatric referral had been missed, and the resident was only referred for psychiatric services after the altercation occurred.
Penalty
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A resident with dementia and repeated resident-to-resident altercations was not comprehensively reassessed after multiple incidents, and the record did not show identification of triggers or updated individualized interventions. Staff described ongoing pillow-taking, room changes, and aggression, but the care plan was not documented as revised. In addition, another resident with severe cognitive impairment and Huntington’s disease was observed repeatedly running barefoot and agitated while staff did not consistently follow the care plan’s interventions such as footwear, ambulation, redirection, snacks, or a calm environment.
Staff failed to appropriately respond to dementia-related behaviors for multiple residents. A resident on a locked memory care unit repeatedly exit-seeked and became aggressive when prevented from going outside, while staff relied on redirection and PRN meds after escalation. Another resident was loudly scolded in the dining room after taking silverware, and a third resident was moved to a med room after wandering into female rooms and undressing, with staff reportedly telling him not to hit them and escalating his behavior. Care plans and notes did not show consistent individualized behavioral management.
A resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance had trazodone reduced from 50 mg to 25 mg after a pharmacy review. Staff later documented increased anxiety, insomnia, wandering, and agitation, and psychiatry recommended increasing trazodone back to 50 mg or even 75 mg nightly, but no order was entered and the resident continued receiving 25 mg. Interviews confirmed the psychiatric recommendation was missed and not addressed.
A resident with Parkinson’s disease, dementia, and major depressive disorder did not have an individualized, person-centered dementia care plan included in the comprehensive care plan. The RNAC confirmed the dementia diagnosis and that the facility failed to develop and implement a dementia care plan for the resident.
A resident admitted with dementia had a care plan that listed only general interventions such as cueing, reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show an individualized person-centered care plan addressing the resident’s specific cognitive loss and dementia-related needs, and the findings were reviewed with the NHA and DON.
A resident with Parkinson’s disease and dementia had documented wandering risk and prior behaviors of entering other residents’ rooms and beds, but the facility did not have a care plan addressing those behaviors before the incident. Staff found the resident in another resident’s bed with his genitals exposed and the other resident’s breast exposed. Interviews showed the assigned 1:1 sitter did not know why supervision was needed, the nurse was unaware of prior behaviors, and the DON reported the IDT typically identifies triggers and interventions, but no documentation showed that this occurred before the event.
Failure to Reassess Dementia Behaviors and Follow Care Plan Interventions
Penalty
Summary
The facility failed to provide appropriate dementia care treatment and services for a resident with moderate cognitive impairment, dementia, anxiety, insomnia, wandering, and rejection of care. The resident’s care plan identified repetitive questions, wandering into other residents’ rooms, and involvement in resident-to-resident altercations as a victim, with interventions such as psychology follow-up, monitoring and documenting mood and behavior, calm approach, removal from crowded areas, one-to-one visits, and introduction to residents with similar interests. The record also noted use of a different colored pillow for forgetfulness and reminders for staff to prompt the resident to carry the special pillow when seen with a white pillow. After repeated resident-to-resident altercations, including incidents in which the resident struck a roommate, fought with another resident over a pillow, slapped a resident in the dining room, and later kicked and hit another resident before being sent to the ER, the medical record did not show that staff reassessed the underlying causes of the behaviors, evaluated whether prior interventions were effective, identified behavioral triggers, or revised the care plan with new individualized interventions. Staff interviews described that the resident wandered with a pillow, took other residents’ pillows, and was moved from room to room after conflicts, but documentation of a comprehensive updated plan of care was not provided. The facility also failed to follow established dementia care interventions for another resident with severe cognitive impairment and Huntington’s disease who had verbal behaviors, agitation, running in the hallway, and physical aggression. The care plan and aide care sheet called for gripper socks or shoes, ambulation with the resident, a calm and quiet environment, reduced noise, snacks or food when agitated or running, wheelchair use when needed, and redirection. During observations, the resident repeatedly ran barefoot through the hallway and in and out of the room, while staff did not provide footwear, walk with the resident, redirect her to slow down, or consistently implement the planned interventions. The dining room television was also observed playing violent scenes at a volume loud enough to interfere with conversation despite the care plan calling for reduced environmental stimulation and a calm environment.
Staff Failed to Respond Appropriately to Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure staff knew how to appropriately respond to, assess, and address behavioral symptoms in residents diagnosed with dementia. The report identifies three residents with dementia-related behaviors who were managed primarily through staff redirection, verbal correction, or PRN medication, rather than through consistent individualized behavioral approaches described in their care plans and the facility’s dementia care policy. One resident, who had dementia and agoraphobia with panic disorder and lived on a locked memory care unit, repeatedly wandered and attempted to exit through doors leading to an enclosed outdoor area. When she became upset and aggressive after being prevented from going outside, multiple staff members responded, and a nurse sought PRN medication to calm her down. Staff statements indicated they usually did not let her go outside or walk with her even though the area was available, and that they relied on PRN medication when she became upset. Her progress notes documented repeated aggressive and exit-seeking behaviors, and her care plan listed wandering and verbal aggression interventions, but the observed response centered on containment, redirection, and medication after escalation. Another resident with dementia and anxiety was observed in the dining room taking silverware from the table and wrapping it in a napkin and placing it in his shirt. A nurse responded in a loud, stern voice, repeatedly telling him not to do it and stating that all new silverware was needed because of him. The resident’s progress notes did not document this behavior, and his care plan did not address the specific utensil-taking behavior. A DON later stated the resident needed to be spoken to calmly because otherwise it would work him up more. A third resident with dementia was reported by his sister and staff to be wandering into female residents’ rooms, trying to remove his clothes, and becoming aggressive. Staff moved him to the medication room and told him not to hit staff, which reportedly escalated his behavior. The sister stated staff seemed shocked by his wandering despite his dementia and believed they lacked training on how to handle the behavior. The resident’s progress notes documented wandering into female peers’ rooms, undressing, and becoming combative, while his care plan addressed general behavior issues with calm approach, diversion, and removal from the situation, but the events described showed staff responses that were loud, reactive, and not aligned with those approaches.
Psychiatric trazodone recommendation not implemented for resident with dementia and wandering
Penalty
Summary
The facility failed to address psychiatric NP recommendations to increase trazodone for a resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance. The resident was admitted with diagnoses that included dementia, anxiety, restlessness, and agitation, and had a documented pattern of exit-seeking, wandering, refusing medications, and requiring 1:1 supervision. Trazodone had initially been ordered at 50 mg at bedtime, then reduced to 25 mg after a pharmacy recommendation for gradual dose reduction was accepted by the NP. After the dose was reduced, an NP progress note documented that staff reported increased anxiety and insomnia and that the resident had failed the dose reduction, but the order remained at 25 mg at bedtime. The record showed no new order to increase trazodone back to 50 mg at that time. Nursing notes later documented ongoing wandering throughout the night, the resident entering another resident’s room, being found in another resident’s bed, and becoming agitated and combative when redirected. The care plan continued to identify behavioral symptoms including restlessness, anxiety, agitation, wandering, and exit-seeking. A psychiatric assessment noted significant cognitive and behavioral challenges, agitation, suspicious behavior, and a history of violent behavior, and indicated medication management services were needed. A psychiatric follow-up later recommended increasing trazodone to 50 mg or 75 mg nightly for sleep and restlessness, but the MAR showed the resident continued to receive 25 mg nightly and no corresponding order was found. Interviews with the Clinical Coordinator, NP, Psychiatric NP, and DON confirmed that the psychiatric recommendation to increase trazodone was missed and not addressed, and the NP stated it was her error and that she thought the medication had been discontinued completely.
Missing Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan to address dementia for Resident R20. The facility policy on comprehensive care plans stated that each care plan should include measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and should describe the services and care to be furnished to attain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident R20 was admitted to the facility and the MDS indicated diagnoses of Parkinson’s disease, dementia, and major depressive disorder. Review of the clinical record showed that the resident’s care plans did not include a care plan for dementia. During interviews, the RNAC confirmed that Resident R20 had a diagnosis of dementia and that a dementia care plan was not included in the comprehensive care plans, and also confirmed that the facility failed to develop and implement an individualized person-centered care plan to address dementia for this resident.
Failure to Individualize Dementia Care Plan
Penalty
Summary
Failure to provide appropriate treatment and services for dementia was identified for Resident 11, who was admitted on April 3, 2026 with a diagnosis including dementia, described as loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life. Review of the resident’s current care plan for impaired cognitive function/dementia or impaired thought processes related to dementia showed only general interventions such as cueing and reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show that the facility had implemented an individualized person-centered care plan to address the resident’s specific dementia and cognitive loss needs. The findings were reviewed with the NHA and DON on June 17, 2026 at 12:10 PM.
Failure to Address Dementia-Related Wandering and Inappropriate Bed Entry
Penalty
Summary
The facility failed to implement effective interventions for a resident with dementia-related behaviors in a timely manner. The resident, who had diagnoses including Parkinson’s disease and dementia, was documented as being at risk for wandering on wandering risk assessments, and prior progress notes described him urinating in his hat and garbage can, sitting in another resident’s bed, and becoming agitated when redirected from another resident’s room. Despite these documented behaviors and collateral information noting a history of wandering and searching behaviors related to his deceased spouse, there was no care plan addressing the resident’s known wandering risk until after the incident in which he was found in another resident’s bed. On the day of the incident, staff found the resident in another resident’s bed under the covers with the other resident. The resident was undressed from the waist down, his genitals were exposed, and the other resident’s breast was exposed. The resident stated he did not know what happened and did not remember, and when asked why he took off his brief, he said it was dirty. The record also showed that the resident had been moved to a new room on the second floor, but there was no documentation explaining why the room change was made. Interviews with staff showed that the CNA who was assigned as a 1:1 sitter did not know why the resident required that supervision and believed it may have been because he wandered into other residents’ rooms. The nurse assigned to the resident reported being unaware of prior wandering or sexual behaviors, although she had heard reports that he wandered into other residents’ rooms. The DON stated the resident was placed on the second floor and that the IDT typically identified triggers and interventions for wandering behaviors, but no documentation was found showing the IDT monitored the resident’s wandering pattern or identified triggers before the incident. The facility’s behavioral management policy stated that the IDT would identify causes of behavior changes, document and track behaviors, and address behaviors and interventions in the care plan.
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