Failure to Provide Individualized Dementia Interventions and Update Care Plans
Penalty
Summary
The facility failed to provide individualized interventions for dementia care to reduce or eliminate the need for psychoactive medications for a resident diagnosed with dementia and other mental health conditions. The resident had multiple diagnoses, including dementia with agitation, diabetes mellitus, insomnia, major depressive disorder, generalized anxiety disorder, and delusional disorder. The resident was prescribed several psychoactive medications, including antipsychotics, antidepressants, and anti-anxiety medications. Despite the use of these medications, the resident continued to display behavioral symptoms such as aggression, resistance to care, and agitation. Over a five-month period, documentation showed that the majority of the resident's behavioral events were successfully managed with non-chemical interventions, such as redirection, snacks, changing caregivers, and removing the resident from overstimulating environments. However, the care plans for the resident were not updated to reflect these effective non-pharmacological approaches, nor were resolved behavioral issues identified as such. The care plans also lacked new or personalized interventions, and there was no assessment of possible triggers for the resident's behaviors. Many care plan problems had not been updated for extended periods, and no new approaches were added despite changes in the resident's behavior and the effectiveness of non-chemical interventions. Interviews with staff confirmed that the resident responded well to individualized, non-pharmacological interventions, such as conversation, snacks, movies, and switching caregivers. Staff also noted that the resident did not experience hallucinations or delusions during the assessment period, and that most behaviors were typical of dementia. Despite this, the facility continued to justify the ongoing use of psychoactive medications without updating the care plan to reflect the resident's current needs and effective interventions. The facility's policy required person-centered, individualized care, but this was not consistently implemented for the resident in question.