Failure to Document and Update Care Plan for Resident with Dementia-Related Behaviors
Penalty
Summary
The facility failed to timely document and update the care plan with new interventions for a resident diagnosed with dementia who exhibited wandering and inappropriate urination behaviors. The resident, who had severe cognitive impairment due to Alzheimer's disease and was occasionally incontinent, was noted to have entered another resident's room and used their bed, which caused distress to the other resident. Although staff were aware of the resident's wandering and incontinence, and interventions such as redirection and routine toileting were in place, there was no documentation of the specific incident in the clinical record, nor were new interventions, such as the use of stop signs on doors, implemented or added to the care plan. Interviews with staff revealed that the resident's behaviors, including wandering into other residents' rooms and using their beds or bathrooms, were known issues. The Weekend Supervisor had suggested using stop signs as a deterrent, but this intervention was not communicated to or recalled by the DON, and no stop signs were observed in the facility. The Social Service Director confirmed that no new interventions had been attempted to help the resident better identify his own room, and that behavior documentation and review processes were inconsistently followed. The facility's behavior management policy required that new or worsening behaviors be documented and reviewed by the interdisciplinary team, with care plans updated as needed. However, the incident involving the resident entering another's room and the associated behaviors were not documented in the clinical record, and the care plan was not updated with new interventions. This lack of timely documentation and failure to initiate or implement new interventions contributed to the deficiency cited during the survey.