Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate, person-centered care and services to two residents diagnosed with dementia, resulting in deficiencies related to the residents' physical, mental, and psychosocial well-being. For one resident with severe cognitive impairment and multiple comorbidities, including diabetes and hearing loss, staff did not respond to repeated requests to go to bed, instead redirecting him to the dining area for lunch without offering individualized interventions. Observations showed the resident repeatedly returning to his room, engaging in repetitive rolling motions in his wheelchair, and calling for help, but staff did not address these behaviors with person-centered care or update the care plan to reflect his needs and preferences prior to the survey. The care plan for this resident lacked interventions addressing his repetitive behaviors, requests for help, and desire to go to bed, focusing instead on general communication and medication encouragement. Although the activities care plan noted some preferences, it did not include the resident's request to go to bed until after the survey began. Staff interviews confirmed a lack of knowledge about effective interventions for redirecting the resident to meaningful activities and acknowledged insufficient documentation of observed behaviors and attempted interventions. For another resident with moderate cognitive impairment, Parkinson's disease, and a history of stroke, the facility did not adequately address wandering behaviors, particularly the resident's tendency to enter other residents' rooms. The care plan failed to specify interventions to prevent this behavior or document the resident's preferences. Progress notes and behavior monitoring records showed inconsistent documentation of interventions used and their effectiveness. Interviews with staff and other residents revealed ongoing issues with wandering and a lack of clear strategies to manage or redirect the behavior.