Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Resident R88, who was admitted to the facility in March 2021, was diagnosed with non-Alzheimer's dementia in January 2023. Despite this diagnosis, a review of the resident's care plan on January 25, 2025, revealed that there were no measurable goals or interventions in place to address the resident's dementia care needs. This lack of a specific care plan was confirmed by the Director of Nursing during an interview. The resident's Minimum Data Set (MDS) assessment, dated December 16, 2024, indicated active diagnoses of non-Alzheimer's dementia and the use of antipsychotic and antidepressant medications. However, the facility did not have a care plan tailored to the resident's dementia care requirements, which is a violation of the requirement to provide appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
Plan Of Correction
1. R88's care plan has been updated to include a personalized care plan to address the residents' dementia care needs. Staff that care for R88 were educated about the changes to the care plan. 2. An audit was completed for residents with a diagnosis of dementia to ensure that a personalized care plan was developed to address their dementia care needs. 3. Education was completed with licensed nurses on the requirements for developing a personalized care plan to address each resident's dementia care needs. 4. The DON/Designee will audit new residents with a diagnosis of dementia weekly x 4 then monthly x 2 months to ensure there is a personalized care plan in place to address the resident's dementia care needs. Findings of the audits will be reported to monthly QA x3.