Failure to Implement Individualized Dementia Care Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to implement resident-specific interventions for a resident diagnosed with early onset Alzheimer's disease and anxiety disorder, who exhibited known behaviors such as intrusive wandering, verbal and physical aggression, and exit-seeking. Despite documented incidents of aggression and altercations at a previous facility, as well as multiple episodes of wandering and combative behavior upon admission, the care plans for this resident did not include individualized interventions addressing these behaviors. The care plans lacked updates to reflect the resident's history of altercations, exit-seeking, and aggressive behaviors, and did not document the implementation of increased monitoring or 15-minute checks as ordered. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, including the room of another resident who later sustained significant injuries. Staff were aware of the resident's aggressive tendencies and history of entering other residents' rooms, but monitoring was inconsistent, and staff were not always positioned to observe the resident's movements. On the night of the incident, staff were occupied with care for another resident and were not able to maintain continuous observation, allowing the resident to enter another resident's room unsupervised. As a result, the resident was found leaving the room of another resident who was discovered on the floor with skin tears, scratches, and later diagnosed with a clavicle fracture and subdural hematoma. The injured resident subsequently died. Documentation and staff interviews confirmed that the facility did not have a behavior management policy available during the survey, and there was a lack of clear, individualized interventions or consistent monitoring to address the known risks associated with the resident's dementia-related behaviors.