Failure to Individualize Dementia Care Plan and Interventions
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident diagnosed with dementia who exhibited aggressive and resistive behaviors. Despite documented incidents of physical aggression, such as hitting another resident and staff, as well as verbal outbursts and resistance to care, the care plan was not updated to reflect these specific behaviors or to include personalized nonpharmacological interventions. The behavior monitoring and intervention report used was generic and did not identify targeted behaviors or individualized approaches for the resident. Multiple staff interviews confirmed that the resident was consistently combative, resistive to care, and had difficulty understanding verbal cues due to dementia. Staff reported using the same general interventions for all residents, without tailoring strategies to the resident's unique needs or updating the care plan after significant incidents, such as physical altercations and falls. Staff also acknowledged that alternative approaches, such as using visual cues or involving staff members with whom the resident responded better, were not attempted during episodes of resistance. Documentation reviewed showed repeated instances of the resident refusing care, exhibiting physical and verbal aggression, and experiencing falls during care attempts. The facility's own dementia care protocol required individualized care planning and communication of resident needs, but these steps were not followed. The lack of specific, updated interventions and failure to address the resident's behaviors in the care plan contributed to ongoing incidents affecting both the resident and others in the facility.