Failure to Develop and Implement Individualized Care Plan for Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to develop and implement an individualized, person-centered care plan for a resident with dementia and Alzheimer's disease. The resident had a documented history of being resistive to care, particularly with activities of daily living such as bathing. The care plan included an intervention for staff to reassure the resident, leave, and return 5-10 minutes later if the resident resisted care. However, during a morning shower, a CNA did not follow this intervention and instead proceeded with the shower despite the resident becoming combative. The CNA admitted to grabbing the resident's hands and continuing with the shower, resulting in the resident sustaining redness, swelling, and tenderness to her wrist, which required medical evaluation and treatment. Additionally, the care plan failed to address the resident's preference for afternoon showers, a preference known to regular staff and the resident's family. The resident was not a morning person and was more cooperative with showers in the afternoon. This information was not included in the care plan, and the CNA who provided care that day was unaware of this preference, leading to increased resistance and the subsequent incident. Observations and interviews confirmed that the care plan did not reflect the resident's specific needs and preferences regarding the timing of showers. The DON acknowledged that the care plan lacked this critical information and that the staff did not follow the existing intervention to leave and return later when the resident resisted care. These failures contributed to the resident's combative behavior and the injury sustained during the shower.