Failure to Implement Individualized Care Plan for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with dementia, who exhibited behavioral symptoms such as agitation, aggression, and delusional ideation. The resident, admitted with dementia and agitation, displayed recurrent episodes of increased agitation, aggressive and argumentative behaviors, verbal threats, and delusional beliefs, including thinking another resident was her daughter and that staff had taken her daughter. These behaviors were documented in multiple progress notes over several months, indicating a pattern of distress and confusion. Despite these documented behaviors, the resident's care plan did not identify specific behavioral symptoms or include individualized interventions tailored to address each behavior. The care plan also failed to incorporate the resident's preferences, social and past life history, customary routines, and interests to support behavior management. An interview with the Nursing Home Administrator confirmed the absence of an individualized, person-centered care plan to manage the resident's dementia-related behaviors, leading to the deficiency finding.
Plan Of Correction
Resident 10 care plan has been updated to reflect specific behavioral symptoms, interventions, resident preferences and interests. Residents with dementia diagnosis will be audited to ensure the presence of personalized interventions related to resident specific behaviors. Nursing staff will be re-educated on resident specific care plans and behaviors related to dementia. Audits will be completed on new admissions with diagnosis of dementia to ensure the presence of resident specific behaviors and interventions in the care plan weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.