Failure to Implement Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia. Resident 18 was admitted with a diagnosis of dementia and was assessed as severely cognitively impaired. However, the facility did not create a care plan that addressed the resident's dementia-related behavioral symptoms, nor did it include interventions based on the resident's preferences, social history, or interests. This lack of a tailored care plan meant that the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety were not maximized through individualized, non-pharmacological approaches. Similarly, Resident 19, who was diagnosed with Dementia with Lewy Bodies and also assessed as severely cognitively impaired, did not have an individualized care plan addressing their specific needs. The care plan in place failed to incorporate the resident's preferences, past life history, and customary routines to manage or decrease dementia-related behavioral symptoms. An interview with the Nursing Home Administrator confirmed the absence of evidence for the development and implementation of such individualized care plans for both residents.
Plan Of Correction
Resident 18 is deceased and resident 19 dementia care plan has been added. To identify other residents with the potential to be affected, the DON/designee completed an audit of all residents with dementia diagnosis to ensure care plan was developed and met residents individualized needs and care. To prevent this from re-occurring, the DON/designee educated the licensed nursing staff on dementia, specific individualized needs and plan of care. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions with a diagnosis of dementia to confirm all care plans meet resident's individualized needs and care weekly then monthly x 2. All results will be brought to QAPI committee.