Failure to Provide Consistent Dementia Care and Person-Centered Interventions
Penalty
Summary
The facility failed to provide consistent and appropriate dementia-related care services to multiple residents diagnosed with dementia and related cognitive impairments. Several residents exhibited behaviors such as physical and verbal aggression, wandering, entering other residents' rooms, taking belongings, and combative actions during activities of daily living (ADLs). Despite these ongoing behaviors, care plans often lacked person-centered interventions and specific staff directions tailored to the residents' individual needs. Staff responses were generally limited to redirection and reapproaching, which were frequently ineffective, and there was a lack of documented individualized strategies to address the challenging behaviors. For example, one resident with a history of strokes and severe cognitive impairment repeatedly became verbally and physically aggressive during ADL assistance, resulting in incidents such as hitting, pinching, and biting staff, as well as sustaining skin tears. Staff attempted redirection with minimal effect, and interviews revealed uncertainty among staff regarding the availability of person-centered interventions in the care plan. Another resident with severe cognitive impairment and a history of dementia exhibited wandering, aggression, and inappropriate behaviors, including entering other residents' rooms, taking items, and physical altercations with peers. Staff were observed intervening only after incidents occurred, and the care plan did not provide detailed, individualized interventions for these behaviors. Additional residents with dementia and related diagnoses were observed engaging in behaviors such as grabbing food from others, entering peers' rooms, and taking belongings. Staff interviews confirmed that supervision and redirection were expected, but there was a lack of clear, person-centered guidance in care plans. The facility was unable to provide a policy related to dementia care when requested, and the observed and documented deficiencies placed residents at risk for decreased quality of life, isolation, and impaired dignity, as noted in the report.