Inadequate Staffing and Supervision of Residents with Dementia
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to manage and supervise the wandering and aggressive behaviors of two residents, identified as Residents 4 and 20. Resident 4, admitted with dementia and violent behavior, exhibited frequent incidents of wandering into other residents' rooms, exit-seeking behaviors, and aggression towards staff and other residents. Despite interventions outlined in the resident's care plan, such as 15-minute checks and redirection, these behaviors persisted, leading to a subacute fracture of the resident's left foot, raising concerns about the adequacy of supervision. Resident 20, also admitted with dementia, displayed similar behaviors, including wandering into other residents' rooms, verbal aggression, and physical aggression, such as attempting to strike staff members with a cane. The care plan for Resident 20 included interventions like the use of a wander guard system and calm redirection, but these measures were insufficient to manage the resident's behaviors effectively. Interviews with residents and staff revealed that the presence of Residents 4 and 20 caused fear and discomfort among other residents, with reports of intrusions into personal spaces and aggressive encounters. The facility's management, including the Nursing Home Administrator and Director of Nursing, were unaware of the extent of these behavioral incidents and could not provide evidence of sufficient staffing with appropriate skills on the B-Wing. Interviews with staff indicated that the facility did not assign enough personnel to manage the behaviors and conduct the required checks, leading to repeated incidents of resident-on-resident intrusions and safety concerns.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. FTAG 741- Sufficient/Competent Staff-Behavioral Health Needs- supervision and safety of residents. 1. Facility unable to retroactively correct sited deficient practice. 2. Identified behavioral residents, residents #4 and #20, to be assessed and evaluated with Behavioral Health Services. 3. Identified residents #4 and #20 current recreational activity plan of care to be reviewed and evaluated. Based on additional needs identified, recreational activity schedule to be adjusted to meet needs of residents. 4. 30 day-look back of current facility residents with diagnosis of Dementia reviewed for any repeated incidents of resident-on-resident, intrusions, aggressive behaviors, and safety concerns. 5. Residents identified with repeated behavior will be assessed and evaluated with Behavioral Health Services. 6. Current staff will be educated on meeting the needs of behavioral residents. 7. Recreational Activity will assess identified residents and implement resident centered activities program. 8. Clinical team will review previous day incident reports involving identified residents related to behavioral health to ensure interventions meet identified residents' behavioral health needs. 9. NHA/Designee will conduct weekly audits x4 then monthly audits x2 to ensure behavioral health needs are being met clinically and socially. 10. Results of audits will be reviewed during facility QA meeting. 11. Date of Compliance March 7, 2025.