Failure to Provide Individualized Dementia Care and Unauthorized Use of Aroma Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia did not receive individualized care interventions as outlined in their care plan. The resident, who had a BIMS score indicating severe cognitive impairment and a history of dementia and cognitive communication deficit, was subjected to actions by a CNA that were not authorized or tailored to their needs. The care plan specified approaches such as allowing extra time for responses, using simple instructions, and providing cues, but these were not followed during the incident. On the night in question, the resident became agitated and began yelling in the hallway. A CNA responded by pulling the resident's gown up over their mouth and spraying an aroma therapy mist directly at the resident's face, actions which were not part of the resident's care plan and had no physician order. This intervention caused the resident to become further agitated, resulting in physical resistance and distress. Other staff members witnessed the incident and reported that the resident only calmed down after alternative, individualized calming strategies were used. Interviews with staff revealed that the CNA had not received required dementia care training and had independently brought the aroma therapy spray into the facility without authorization from nursing or medical staff. Multiple staff members confirmed that the use of aroma therapy mist was not approved or ordered for any residents, and the facility's policy required individualized, person-centered interventions for dementia care. The facility also had not been monitoring staff compliance with required dementia care training at the time of the incident.
Plan Of Correction
Resident #103 no longer resides in the facility. Facility residents with a diagnosis of dementia have the potential to be affected. The DON/Designee conducted an audit to identify those residents who have been diagnosed with dementia and were reviewed by the Interdisciplinary Team for appropriate interventions. Their personalized care plans will be reviewed for accuracy on or by 7/11/25. The SDC/Designee will educate nurses and CNAs on the Caring for Dementia policy, creating and following individualized care plan interventions, 10-Tips to De-Escalate Challenging Situations, and Tips for Managing Agitation, Aggression, and Sundowning on or before 7/14/25. Staff will not be allowed to work until education is completed. The DON/designee will complete audits three times a week for eight weeks or until substantial compliance is achieved of newly admitted and readmitted residents with a dementia diagnosis to ensure their care plan includes individualized interventions. Results of the audits will be submitted to the QAPI committee for its review and recommendations. The Director of Nursing is responsible for ongoing compliance.