Failure to Provide Effective Dementia-Related Behavioral Services
Penalty
Summary
The facility failed to provide appropriate dementia-related behavioral services to a resident diagnosed with acute encephalopathy, abnormal behaviors, and acute kidney injury, who exhibited moderate cognitive impairment, hallucinations, delusions, and daily wandering. Despite being care planned as an elopement risk and requiring supervision for certain activities, the resident was repeatedly observed entering another resident's room, attempting to change clothes, and interacting with personal belongings without staff intervention. Progress notes and staff interviews confirmed ongoing incidents of the resident entering the same male resident's room, attempting to undress, and being redirected multiple times, with staff acknowledging the ineffectiveness of their interventions to prevent these behaviors. Observations documented that the resident was able to wander unmonitored into other residents' rooms, causing distress to the male resident involved, who reported the issue to staff on several occasions. The facility's policy required individualized care interventions and the use of the least restrictive approaches, but the interventions implemented were not successful in addressing the resident's wandering and inappropriate room entry behaviors. The lack of effective behavioral services and monitoring resulted in repeated incidents and placed the resident at risk for decreased quality of life and impaired dignity.