Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with vascular dementia, who displayed aggressive and wandering behaviors. The resident, admitted on November 20, 2024, was noted to be severely cognitively impaired with a BIMS score of 5. Despite a physician's order for 1:1 supervision due to aggressive and disruptive behaviors, the facility did not consistently implement this intervention. The care plan initiated on November 21, 2024, lacked specific interventions to address the resident's aggressive and wandering behaviors, which led to multiple instances of verbal and physical aggression and an elopement incident. Facility documentation revealed that the resident eloped through an open hallway window and was involved in several aggressive incidents towards staff and other residents. On December 27, 2024, the resident was physically restrained by staff, including being grabbed around the neck. Interviews with the Nursing Home Administrator confirmed that the facility's dementia program, which was updated after a previous survey, was not effectively implemented for this resident. The program was supposed to provide individualized, person-centered interventions, but the resident's care plan did not reflect these practices.
Plan Of Correction
- A16 care plan reviewed and developed an individualized person centered plan of care to address and manage dementia related behaviors. Current residents residing on the C1 and D units will have their care plans reviewed and updated to be individualized and person centered to address any dementia related behaviors. - Current dementia programming reviewed and updated to meet each of the resident behavior needs. Mandatory Directed In-service training will be completed 2/11/2025 on dementia-related behaviors, person-centered care planning, and behavior management techniques. Training will include de-escalation techniques, recognizing triggers, and effective redirection methods. Competency test will be completed to ensure staff can apply learned techniques. Additional education and support will be provided by the LTC RISE program. - Implementation of a "behavior management" committee will be initiated to include but not limited to nursing, activities, social service, and pharmacy. Pharmacy consultant will provide monthly recommendations for gradual dose reduction (GDR) requirements, focusing on reducing unnecessary medications and implementing alternative, non-pharmacological interventions. - Ongoing care conferences will continue with residents and/or resident representative (RR) to discuss behavioral interventions and gather input on personalized care approaches. RR will be offered on dementia care and strategies they can reinforce during visits. - DON or designee will be responsible to oversee implementation and compliance and conduct audits of care plans and direct observations of residents. - Root cause analysis will be conducted in coordination of the QAPI committee and governing body. The result of the RCA will be incorporated into the POC. - The DON or designee will conduct weekly audits x 4 weeks, then monthly x 2 of dementia care and individualized person center care. Audits will be presented at the monthly QAPI committee for ongoing oversight.