Failure to Document and Monitor Dementia Care Interventions
Penalty
Summary
The facility failed to implement and document dementia care interventions for a resident diagnosed with dementia, as required by its own policies and procedures. The resident, who had a history of dementia and was noted to lack capacity for medical decision-making, was observed to be confused, sometimes agitated, and in need of reminders to eat. Staff interviews revealed that while changes in the resident's behavior, such as agitation and aggression, were verbally reported to the charge nurse, there was no documentation or formal monitoring of these behaviors in the medical record as outlined in the resident's care plan. Review of the resident's care plan indicated that staff were to monitor for changes in condition and behaviors related to dementia and report these findings to the physician. However, both CNA and LVN staff confirmed that they did not document altered behaviors or assess for changes in the resident's thought process, despite observing such behaviors. The lack of documentation and monitoring meant that the resident's dementia-related symptoms and potential changes in condition were not being formally tracked or communicated as required.