Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to address the dementia-related behavioral symptoms of a resident diagnosed with severe cognitive impairment. The resident, who was admitted with a diagnosis of dementia, exhibited increased behaviors such as self-rising, anxiety, and restlessness almost daily during the month of April 2025. Despite these documented changes in behavior, the resident's care plan, last revised in June 2024, did not include any new interventions or strategies to address these emerging symptoms. A review of the clinical record and care plan revealed no evidence that the facility assessed the resident's preferences, social history, routines, or interests to create individualized, non-pharmacological interventions. There was also no documentation of purposeful or meaningful activities tailored to the resident's needs to enhance well-being. An interview with the Nursing Home Administrator confirmed that the facility could not provide evidence of having developed or implemented a person-centered plan for the resident's dementia care.