Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dementia diagnosis and related care needs for a resident with a documented history of dementia. The resident's admission record included multiple diagnoses, such as type 2 diabetes mellitus, dysphagia, major depressive disorder, dementia, and anxiety disorder. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment with a BIMS score of 12. Despite these findings, the resident's current care plan did not address dementia or any associated care needs. Observations over several days showed the resident sitting in the dementia unit dining room without any engagement or activities, and staff interviews confirmed fluctuations in the resident's cognitive status. The Care Plan Coordinator acknowledged that the care plan lacked any interventions or goals related to dementia care, and the facility's own policy required comprehensive evaluation and care planning for individuals with dementia. The deficiency was identified through record review, staff interviews, and direct observation.