Failure to Provide Appropriate Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate supervision, treatment, and services to a resident diagnosed with dementia, anxiety, and major depressive disorder, who also exhibited aggressive behaviors. The resident's medical record documented moderately impaired cognition, inattention, disorganized thinking, and fluctuating levels of consciousness, as well as frequent pain and total incontinence. The care plan identified risks for outbursts, yelling, spitting, and refusal of care, and directed staff to use redirection, paired care, and activity engagement as interventions. Despite these documented interventions, multiple progress notes and staff interviews revealed ongoing incidents of verbal aggression, refusal of care, and inappropriate interactions with other residents, including the use of profanity, threats, and physical actions such as throwing objects. Staff reported that the resident was not easily redirected and required separation from another resident due to behavioral issues. The care plan also included consulting mental health services and medication management, but the facility was unable to provide a dementia behavior management policy when requested. Observations and interviews confirmed that the resident continued to display aggressive and inappropriate behaviors toward staff and other residents, indicating that the facility did not consistently implement or document effective behavioral management strategies as outlined in the care plan.