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F0744
E

Failure to Implement Non-Pharmacological Interventions for Residents with Dementia

Dubois, Pennsylvania Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, as required by their own policy and regulatory standards. Both residents exhibited ongoing behavioral symptoms such as agitation, wandering, entering other residents' rooms, and interfering with others' belongings. Despite these persistent behaviors, there was no documented evidence that new or alternative non-pharmacological interventions were attempted to address these issues, aside from adjustments to their medications. One resident, with diagnoses including Alzheimer's disease and adjustment disorder, was noted to be severely cognitively impaired and displayed behaviors such as verbal outbursts, wandering, rummaging, and inappropriate use of other residents' belongings. Nursing notes over several months documented repeated incidents of agitation, anxiety, and disruptive behaviors, including entering other residents' rooms and taking their clothing. The care plan referenced some general activity offerings and support, but there was no documentation of new or individualized interventions being implemented in response to the ongoing behaviors. Another resident, also severely cognitively impaired with a diagnosis of dementia, demonstrated daily wandering, physical and verbal behavioral symptoms, and inappropriate interactions with other residents and their property. Despite care plans that suggested offering diversional tasks and activities tailored to the resident's interests, nursing documentation showed that these interventions were either ineffective or not consistently attempted. The only documented responses to the resident's escalating behaviors were medication adjustments and a hospital admission, with no evidence of new non-pharmacological strategies being tried. Interviews with the Director of Nursing confirmed the lack of documented new interventions for both residents.

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