Inaccurate Psychiatric Assessment of Resident with Dementia
Summary
The facility failed to appropriately assess a resident diagnosed with dementia and other conditions, including encephalopathy, aphasia, and dysphagia, following a cerebrovascular accident. During observations, the resident was noted to be nonverbal and sleepy, with a history of stroke and anxiety. Despite these observations, the psychiatric assessments conducted on two consecutive days in July inaccurately documented the resident's speech, thought process, and other mental health indicators as normal and organized. These discrepancies were attributed to transcription errors and typos by the psychiatric staff involved. The psychiatric assessments failed to accurately reflect the resident's condition, as noted by the surveyor and confirmed by the psychiatric staff during interviews. The assessments incorrectly described the resident's speech and thought processes, and included inappropriate counseling recommendations such as sleep hygiene and mindfulness, which were not suitable given the resident's nonverbal state and cognitive impairments. These errors were acknowledged by the psychiatric staff, who admitted to mistakes in their documentation.
Penalty
Resources
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Two residents with dementia and known histories of sexually inappropriate behaviors were not provided with consistent, individualized behavioral health interventions, monitoring, or supervision. One resident had repeated documented sexual incidents with other residents and was intermittently placed on 1:1 observation or q15‑minute checks, which were later discontinued without clear rationale or provider authorization. Another resident with severely impaired cognition had multiple episodes of public masturbation and concerns raised by family about his behavior and medication, yet after he was moved to a secured unit due to inappropriate touching of another resident, there was no documented increase in monitoring or reassessment. Staff concerns about placing this resident on a unit with more cognitively impaired and vulnerable residents were not effectively acted upon, and no enhanced supervision was implemented. Subsequently, staff found the two residents in a bedroom, partially undressed and engaged in sexual intercourse, demonstrating the facility’s failure to follow its own dementia and behavior management policies and to provide adequate behavioral health services and supervision.
Staff failed to use appropriate dementia‑focused, person‑centered approaches with two residents who had dementia and documented behavioral symptoms. In one case, a resident with a history of aggression resisted a scheduled shower; despite a care plan directing staff to stop care when the resident became combative and to return later, staff proceeded with the shower while reporting being hit and having hair pulled, and an LPN delayed responding to repeated requests for help while the resident was reportedly aggressive. In the second case, a resident with dementia and a care plan for verbal aggression and disruptive behaviors became frustrated with a staff member’s child who was running around during smoke time and struck the child; afterward, an LPN who was the child’s parent, and not the resident’s nurse, confronted the resident and told the resident she could be charged with assault, taken to jail, and was “lucky” the LPN was staff, rather than using calm, dementia‑appropriate communication as outlined in facility training and care plans.
A resident with severe dementia, dependent on staff for ADLs, was subjected to inappropriate care when three CNAs physically restrained her wrists during an episode of combativeness, resulting in significant bruising. Despite care plans and training that directed staff to respect the resident's right to refuse care and to use non-physical interventions, staff proceeded with care by holding her down, contrary to facility policy and best practices for dementia care.
The facility did not provide specialized memory care services as advertised, with residents on the memory care unit receiving the same activities as the rest of the facility and lacking individualized programming. Observations and staff interviews revealed minimal engagement, no separate activity calendar, and inadequate staffing, resulting in periods of unsupervised residents and unmet psychosocial needs. Families and staff expressed concerns about the lack of stimulation, safety, and the absence of meaningful activities tailored to residents with dementia.
Two residents did not receive comprehensive dementia care services due to inadequate staffing, resulting in missed personal hygiene assistance and scheduled activities. Residents were left unsupervised, and planned activities were not conducted as listed, with staff confirming challenges in providing care and supervision due to limited personnel.
Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services, including non‑pharmacological interventions, for residents with dementia and behavioral disturbances, which resulted in resident‑to‑resident altercations and actual harm. Two residents with dementia and significant behavioral histories repeatedly wandered, entered other residents’ rooms, and displayed agitation and aggression without evidence of effective monitoring or individualized non‑pharmacological strategies to manage these behaviors or prevent altercations. The facility relied heavily on psychotropic medication adjustments and brief periods of increased supervision, without documenting or care‑planning specific behavioral interventions tailored to each resident’s needs. One resident had vascular dementia with behavioral disturbance, agitation, anxiety, sundowning, combative behavior at night, and a history of throwing a chair, walking naked, and visual hallucinations. Orders included multiple psychotropic medications such as Haldol, Ativan, Vistaril, Depakote, Trazodone, and later Klonopin, with several dose changes over time. Nursing notes repeatedly documented this resident wandering the halls, entering other residents’ rooms, pacing, yelling, slamming chairs and doors, being verbally and physically aggressive, and having explosive episodes. The care plan identified mood and behavior problems, including disruptive behavior, resisting care, socially inappropriate behavior, wandering into other rooms, exit seeking, and combativeness, but listed only general interventions such as consulting social services, administering medications, monitoring behaviors, and gentle redirection. There was no documented evidence of specific non‑pharmacological interventions being planned or implemented to address these behaviors. The second resident had diagnoses including behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, delirium, and later severely impaired cognition, with documented behaviors such as wandering daily, rejecting care, and physical and verbal behaviors toward others. This resident frequently wandered into other residents’ rooms and was found in their recliners or beds, yet the record showed no non‑pharmacological interventions to address wandering or to prevent altercations. Multiple incidents occurred between the two residents: one resident hit the other on the jaw while the victim sat near the nurse’s station; on another occasion, one resident repeatedly rammed a walker into the other’s legs, leading to mutual hitting and facial scratches; and later, the wandering resident entered the other’s room, resulting in a serious altercation where the victim was found on the floor with significant facial trauma, periorbital swelling, scalp laceration, and a large bruise from hip to knee. Despite these escalating events and the known mutual dislike between the two residents, interviews and record review confirmed that no new, individualized non‑pharmacological interventions were added beyond temporary increased or one‑on‑one supervision, and the facility did not effectively implement behavioral health services to prevent further resident‑to‑resident altercations. Title: Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations ShortSummary: Two residents with dementia and significant behavioral histories repeatedly wandered, entered other rooms, and displayed agitation and aggression without individualized non‑pharmacological interventions or effective behavioral health care plans. Staff documented frequent wandering, pacing, yelling, slamming furniture, and explosive episodes, and the care plans relied largely on psychotropic medications and general redirection rather than specific, person‑centered strategies. Multiple altercations occurred, including one resident striking another near the nurse’s station, an incident involving a walker being rammed into another resident’s legs with mutual hitting and facial scratches, and a later episode in which a wandering resident entered another’s room and sustained significant facial trauma, scalp laceration, and extensive bruising. Records and interviews confirmed that, despite these events and awareness that the two residents did not get along, the facility did not develop or implement comprehensive, individualized non‑pharmacological interventions to manage behaviors or prevent further resident‑to‑resident altercations.
Failure to Provide Adequate Behavioral Health Services and Supervision for Residents With Dementia and Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with dementia and known histories of sexually inappropriate behaviors received adequate and effective behavioral health services, individualized interventions, monitoring, and supervision. One resident with moderately impaired cognition and a long history of sexually inappropriate behaviors had multiple documented incidents over several months, including oral sex with another resident, encouraging a male resident to rub her legs, kissing a male resident in her room, being observed with a male resident’s hands in her pants, repeatedly entering male residents’ rooms, and speaking in explicit sexual detail to her roommate. Her guardian repeatedly expressed concerns and requested increased safety measures, including a transfer to an all-female facility. The resident’s care plan included intermittent periods of one-to-one observation and every 15‑minute checks, but these heightened monitoring interventions were repeatedly started and then resolved, and the 15‑minute checks were discontinued in October without documented rationale or authorization from the psychiatric provider. Another resident with severely impaired cognition and dementia also had a documented history of sexually inappropriate behaviors. His care plan identified sexually inappropriate behavior after an encounter with another resident and included interventions such as behavioral health services, medication management, and one-to-one observation if sexually inappropriate behavior occurred. He was prescribed cimetidine (Tagamet) off-label to reduce sexual desire. Nursing notes documented multiple episodes of him touching himself inappropriately in common areas and being redirected to his room, as well as reports from his sister about sexually inappropriate behaviors at his offsite day program and concerns about the effectiveness of his medication. Despite these ongoing behaviors and concerns, after his room was changed to a secured unit due to inappropriate touching of a female resident, there was no documented evidence of increased monitoring, reassessment, or new interventions between the time of the move and the subsequent incident. The deficiency culminated when the resident with severely impaired cognition and the resident with moderately impaired cognition, both with known sexually inappropriate behaviors, were placed on the same secured unit without reassessment or revision of their behavioral health care plans related to monitoring and supervision. Direct care staff expressed concerns about moving the male resident with sexually inappropriate behaviors to a unit where residents were generally less cognitively aware and more vulnerable, but these concerns were either not communicated to management or not acted upon. No increased monitoring or individualized behavioral interventions were implemented for either resident after the room change. Several days later, staff discovered the two residents in the female resident’s bedroom with both residents partially undressed and engaged in sexual intercourse, confirming that the facility had not provided the necessary behavioral health services, individualized interventions, and supervision required by their conditions and histories. The facility’s own policies on dementia care and behavior assessment required the interdisciplinary team to identify resident-centered care plans, evaluate behavioral symptoms for safety risk, monitor for worsening symptoms, and adjust interventions based on changes in behavior and needs. However, the residents’ ongoing sexually inappropriate behaviors, repeated incidents, guardian concerns, and changes in placement were not accompanied by consistent reassessment, documentation, or adjustment of monitoring and supervision. The psychiatric mental health nurse practitioner reported she was not informed of continued sexually inappropriate behaviors after the male resident’s room change and did not authorize discontinuation of the female resident’s 15‑minute checks, indicating a breakdown in communication and failure to follow established behavioral health protocols that contributed directly to the incident.
Removal Plan
- The DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were notified of the sexual incident with Resident #10; full body skin assessments were completed for Resident #05 and Resident #10.
- Resident #10's guardian was notified by the facility of the sexual incident with Resident #05; the facility requested permission to transfer Resident #10 out of the facility later that day.
- The facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.
- Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905.
- Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.
- Resident #10 was discharged to another facility.
- Resident #05 was discharged to another facility.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 interviewed all residents with a BIMS score of 13 and above about inappropriate sexual encounters, reporting, and safety; all residents with a BIMS score of 12 and below had a skin assessment completed to identify any possible changes.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.
- RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 educated all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents (including pre-admission IDT review for sexual behaviors; care planning for residents with dementia or cognitively intact residents with sexual inappropriate behaviors; psychiatric follow-up; immediate notification to nursing management and psychiatric team; immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe).
- ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify documentation of sexual behaviors; five residents (#60, #61, #63, #64, and #65) were placed on every 15-minute checks for inappropriate comments to staff; orders and notifications were completed; direct care staff would complete observations with management completing checks if changes were needed; IDT/psychiatric/physician would determine discontinuation; at-risk residents would be reviewed weekly with changes prompting team discussion and plan of action.
- MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.
- An ad hoc QAPI meeting was held to review the system change for sexually inappropriate residents and education provided to staff (including Medical Director, Activities Director, HRD, Social Services Assistant, Regional Nurse, MDS Nurse, Receptionist, Wound Nurse, and CQAN).
- The facility created an audit tool to be reviewed weekly at standard of care meetings with the IDT to ensure residents were identified and interventions were in place; residents with a diagnosis of sexual behavior or any sexual behavior identified would be audited weekly; the system change would continue ongoing.
- The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.
- The medical records for Residents #60, #61, #63, #64, and #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.
- Direct staff members were observed providing adequate surveillance for Residents #60, #61, #63, #64, and #65 with no issues noted.
- Interviews with RN #191, LPN #504, and CNA #141 verified staff were educated regarding dementia clinical protocol, resident routine checks, and behavioral assessment/intervention/monitoring, and were knowledgeable of residents requiring increased surveillance and the procedure for resident checks.
Failure to Provide Appropriate Dementia‑Focused Care and Responses to Behavioral Incidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff had the skills and used appropriate approaches to provide person‑centered dementia care to two residents with dementia and behavioral symptoms. For one resident with dementia, depression, anxiety, psychosis, and documented physical and verbal aggression, the care plan specified that staff should offer alternatives when care was refused, allow the resident to make choices, maintain a calm environment, approach slowly and calmly, and stop care if the resident became combative, ensuring safety and returning later. Progress notes documented that this resident was confused, resistive, and combative at times, with increased restlessness, anxiety, and verbal aggression. On the night in question, staff reported the resident initially agreed to a shower but then became combative in the shower room, pulling a staff member’s hair and exhibiting aggressive behaviors. According to staff statements and the self‑reported incident, a resident assistant and a trainee CNA reported that the resident was combative during the shower and that they were being hit, bitten, and having hair pulled. The RA sought guidance from an RN, who advised using two aides and suggested one aide watch or hold the resident’s hands as a distraction so the resident would not grab, hit, or pull hair. The RA and CNA reported feeling that they were being forced to complete the shower despite the resident’s resistance. The LPN on duty acknowledged knowing that the resident did not want to be showered and that staff had asked her for help multiple times while they were agitated and reporting aggression. The LPN did not immediately enter the shower room, continued other tasks, and only later went in, at which time she found the resident agitated but not aggressive and used a redirection strategy (offering to take the resident back to her “baby”) to complete drying and dressing. Another CNA later provided care without issues. The LPN verified that if a resident became combative or agitated, staff should stop what they were doing, and also verified she did not immediately assess the situation in the shower room to ensure the resident’s safety. The second component of the deficiency concerns the facility’s failure to ensure staff approached a resident with dementia appropriately after a behavioral incident. This resident had dementia without behavioral disturbance listed among diagnoses but had a care plan for verbal aggression, hallucinations, false accusations, yelling, argumentativeness, insulting comments, and threatening statements, with interventions including removing the resident from overstimulating situations and moving the resident to a quiet, calm environment when behaviors escalated. During an evening smoke break, a staff member’s seven‑year‑old child was outside in the courtyard running around while residents smoked. Multiple statements indicated that the resident became frustrated with the child’s behavior and struck or punched the child in the stomach. The child went inside crying and reported being hit, and a red mark was observed on the child’s abdomen. After the incident, the LPN who was the child’s mother, and who was not the resident’s nurse and had not witnessed the event, confronted the resident near the nurse’s station. The LPN asked if the resident had hit her child; when the resident confirmed, the LPN told the resident that many children come into the facility and that the resident did not have the right to hit children. The LPN further told the resident that she could be charged with assault, could be taken to jail, and that the resident was “lucky” she was a staff member because someone else might press charges. Other staff and resident statements corroborated that the LPN told the resident she was lucky she was there or in there, that she could be leaving in a police car, and that it was not acceptable to hit other people’s children. The LPN acknowledged she was upset, spoke sternly, and believed she was educating the resident about not hitting children, despite knowing the resident had dementia and that the facility was the resident’s home. The facility assessment and training materials indicated that staff were to receive dementia management, person‑centered care, and communication training, but the events described show that staff responses to these residents’ dementia‑related behaviors did not align with the planned dementia‑care approaches.
Failure to Provide Dignified Dementia Care Results in Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate and dignified dementia care to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident required one-person assistance with activities of daily living (ADLs) and had care plans in place that emphasized respecting her right to refuse care, maintaining a calm environment, and not forcing her to complete tasks. Despite these documented approaches, three CNAs attempted to provide incontinence care while the resident was combative, resulting in the staff holding her wrists and arms. This led to significant bruising on both wrists and lower forearms, as confirmed by skin assessments and X-rays ordered due to complaints of pain. The incident was precipitated by the resident's refusal of care and escalating combative behaviors, including hitting, kicking, biting, and pinching. Staff attempted multiple comfort and redirection measures, but these were ineffective. Instead of discontinuing care and re-approaching later, as outlined in the care plan and facility training, the staff proceeded with care by physically restraining the resident's wrists. There was no documentation indicating that the nurse was notified of the resident's escalating behavior or that the situation required immediate intervention for safety. The medical record and investigation did not provide evidence that care could not have been delayed or that the resident was unsafe if care was postponed. Interviews with staff and review of facility policies confirmed that staff were trained to step away and re-approach residents who refused care, and that physical restraint or force was not an acceptable practice. The facility's abuse prevention policy and dementia care training both emphasized the importance of respecting resident rights and using non-physical interventions. Despite this, the staff involved did not follow these protocols, resulting in actual harm to the resident in the form of bruising and pain.
Failure to Provide Specialized Memory Care Services and Activities
Penalty
Summary
The facility failed to provide specialized memory care services as advertised for all residents residing on the memory care unit. Record review showed that multiple residents with diagnoses such as dementia, Alzheimer's disease, depression, and other cognitive impairments were admitted to the unit. Despite facility brochures and fliers promoting a specialized memory care program, interviews with staff and observations revealed that no specific memory care program or specialized activities were implemented. The activities provided to memory care residents were the same as those offered to the rest of the facility, and there was no separate activity calendar or tailored programming for the memory care unit. Observations on the memory care unit showed a lack of engagement and stimulation for residents, with minimal activities occurring and residents often left sitting in common areas or in their rooms without interaction. Staff interviews confirmed that the activity director was unable to provide activities for the memory care unit due to other responsibilities, and activity assessments for these residents were not completed until after they were requested by surveyors. The only activities listed, such as beverage cart and sit and chat, were not consistently provided, and staff did not consider them meaningful activities. Residents were not routinely invited to participate in facility-wide activities, and the activity room was locked when the activity director was not present. Staffing on the memory care unit was consistently reported as inadequate, with only one aide assigned per shift, leading to periods when residents were left unsupervised while staff attended to individual care needs. Staff and family interviews expressed concerns about resident safety and the lack of engagement, stimulation, and supervision. Families reported not being informed about the benefits of memory care and expressed expectations for more specialized activities and higher staffing levels. The facility's own policies and job descriptions outlined requirements for individualized activity programming and assessments, which were not met for the memory care residents.
Failure to Provide Comprehensive Dementia Care and Activities Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide comprehensive, resident-centered services to meet the dementia care needs of residents on the specialty memory care unit. Observations and schedule reviews revealed that staffing was inadequate, with only one CNA and one nurse scheduled on several days. This resulted in residents not receiving timely assistance with personal hygiene, as evidenced by a resident remaining with oatmeal smeared on her sweater sleeve for an extended period. Additionally, scheduled activities intended to promote resident well-being, such as morning stretches, coffee and daily chronicle, and coloring, were not conducted as listed on the activity calendar. Residents were left unsupervised in the dining/activity room, and activity staff did not arrive until later in the day, confirming that planned activities were not provided as scheduled. Further, the lack of staff supervision led to safety concerns, such as a resident entering another resident's room without staff awareness, which was only addressed after being brought to the attention of the nurse. Interviews with staff confirmed the challenges posed by insufficient staffing, including difficulty providing care for residents requiring two-person assistance and the inability to carry out scheduled activities. The administrator acknowledged ongoing staffing shortages due to staff unavailability and training, which contributed to the lack of adequate supervision and activity provision on the memory care unit.
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