Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide necessary person-centered care and services to residents with dementia, as evidenced by multiple direct observations and staff interviews. During a continuous observation of the Alzheimer's unit dining area, a resident with severe cognitive impairment repeatedly requested assistance to use the bathroom but was not promptly assisted by staff, resulting in visible distress and incontinence. Staff were observed prioritizing other tasks, such as feeding residents and documenting, and stated they were not allowed to interrupt these duties to assist with toileting. The resident's care plan did not include progressive, person-centered interventions specific to her dementia diagnosis. Another resident with moderate dementia and behavioral disturbances was observed wandering the hallways and eating food from other residents' plates, despite being on a mechanical soft diet. Staff redirected her only after she had already consumed food from multiple plates. The care plan for this resident also lacked individualized, progressive interventions tailored to her dementia-related needs. Staff interviews confirmed that residents frequently wander into other rooms and that there are insufficient activities and supervision to engage and monitor them effectively. A third resident with severe cognitive impairment was observed handling dirty dishes and smearing food on her hands without appropriate staff intervention until after the fact. Staff interviews and record reviews revealed that staffing levels were inadequate to meet residents' needs in a timely manner, and that activity programming was inconsistent and often disrupted. The care plans for all three residents reviewed did not reflect person-centered, progressive interventions for dementia care, and the facility's own dementia protocol was not followed as required.