Failure to Provide Consistent Dementia Care Services
Penalty
Summary
The facility failed to provide consistent dementia-related care services for a resident diagnosed with dementia, benign prostatic hyperplasia, and acute kidney failure. The resident had severe cognitive impairment, as indicated by a BIMS score of zero, and required substantial to maximal assistance with daily activities, including dressing, hygiene, and mobility. The care plan identified risks such as cognitive loss, incontinence, falls, and skin breakdown, and instructed staff to keep the resident engaged in activities, calmly communicate, and anticipate his needs. However, the care plan lacked specific interventions for managing aggressive behaviors, and staff documentation did not reflect the use of non-pharmacological interventions during episodes of aggression or wandering. Observations and interviews revealed that the resident frequently wandered into peers' rooms and attempted to self-toilet, resulting in non-injury falls. Staff reported difficulty keeping the resident engaged and redirecting him from unsafe areas, but there was no evidence of consistent implementation of individualized behavioral interventions. The facility's dementia care policy required strategies to address triggers and behaviors, but the documentation and staff actions did not demonstrate adherence to these approaches, resulting in a failure to promote the resident's highest practicable level of well-being.