Failure to Develop Dementia Care Plans for Two Residents
Penalty
Summary
The facility failed to develop individualized care plans addressing dementia for two residents who had been diagnosed with the condition. For one resident, records showed diagnoses of dementia, major depressive disorder, schizoaffective disorder, and mood disorder, with severe cognitive impairment and a need for maximal assistance with activities of daily living (ADLs). Despite these findings, there was no care plan in place to address the resident's dementia diagnosis. The MDS nurse confirmed that a care plan was necessary to create individualized goals and interventions, and its absence put the resident at risk of not receiving care tailored to their dementia-related needs. The Director of Nursing also acknowledged that a care plan should have been developed to guide staff in providing appropriate care for the resident's specific needs. Similarly, another resident with diagnoses including dementia, unspecified psychosis, and major depressive disorder, and who required moderate assistance with ADLs, did not have a care plan addressing dementia. The MDS nurse confirmed that no care plan was in place for this diagnosis, which was necessary to identify concerns and establish goals for behaviors associated with dementia. Facility policy required staff to monitor individuals with dementia for changes in condition and to develop individualized, comprehensive care plans to meet medical, nursing, mental, and psychosocial needs, but this was not done for these two residents.