Failure to Address Sleep Disturbances and Behavioral Symptoms
Penalty
Summary
The facility failed to provide appropriate care and treatment for two residents with significant needs. One resident, admitted with diagnoses including squamous cell carcinoma and diabetes, reported ongoing difficulty sleeping due to another resident's persistent yelling and screaming at all hours. Despite repeated complaints to nursing, social work, and management, the only intervention provided was a headphone, which was ineffective. There was no assessment, monitoring, or care plan developed to address the resident's sleep difficulties, and the grievance was not documented or addressed according to facility policy. Another resident, diagnosed with dementia and encephalopathy, exhibited ongoing behavioral disturbances including yelling, screaming, paranoia, and insomnia. Staff interviews and record reviews confirmed that these behaviors were persistent and disruptive, occurring day and night, and were documented in multiple psychiatry notes. Despite this, there was no care plan or interventions implemented to address the resident's insomnia and paranoia, and the behaviors were not accurately reflected in the Minimum Data Set (MDS) assessments. The facility's interdisciplinary team did not evaluate or monitor these behavioral symptoms as required by policy. Facility policies reviewed indicated requirements for accommodating resident needs, providing a homelike environment, addressing grievances, and developing comprehensive, person-centered care plans based on thorough assessments. However, these policies were not followed in the cases of the two residents, resulting in unaddressed sleep disturbances for one and unmanaged behavioral symptoms for the other. The lack of assessment, care planning, and intervention contributed to ongoing issues for both residents.