Failure to Implement and Document Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for one resident diagnosed with dementia. According to the facility's own policy, staff and physicians are required to evaluate, monitor, and document the cognitive and behavioral status of residents with dementia, including signs of altered mood, loss of interest in activities, and other related symptoms. For the resident in question, the care plan specifically called for monitoring and reporting of mood changes and symptoms of depression or anxiety. However, medical record review revealed no documented evidence that these assessments or monitoring activities were being performed as required. Observations and interviews with staff confirmed that the resident exhibited severe cognitive impairment, was dependent for most ADLs, and displayed behaviors such as confusion, aggression, and lack of interaction. Despite these symptoms and the care plan directives, both CNAs and LVNs were unable to provide documentation of behavior or mood monitoring for the resident. The DON also verified that no such documentation existed, confirming that the required interventions and monitoring for dementia-related symptoms were not being carried out as outlined in the resident's plan of care.