Failure to Implement Dementia-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan specifically addressing dementia care and resident-specific interventions for a resident with multiple mental health diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident's medical record showed care plans for verbally abusive behaviors and mental health needs, but there was no care plan that directly addressed dementia or Alzheimer's disease, nor was there mention of a bipolar diagnosis. The interventions listed in the existing care plans focused on general mental health support, such as assessing needs, providing supportive counseling, and involving family, but did not include dementia-specific strategies. A review of the resident's Minimum Data Set (MDS) assessment confirmed cognitive impairment, yet the medical record lacked evidence of a care plan tailored to dementia care. During an interview, the Social Services Director acknowledged the absence of a dementia care plan and stated that one should have been implemented at admission. The facility's current policy requires the interdisciplinary team to create a resident-centered care plan for individuals with confirmed dementia, but this was not done for the resident in question.