Failure to Implement Comprehensive Care Plan for Agitated Resident with Dementia
Penalty
Summary
The facility failed to fully develop and implement a comprehensive care plan for a resident with dementia who was identified as an elopement risk and exhibited agitated behaviors. The care plan included interventions such as offering pleasant diversions and approaching the resident in a calm manner, but the section for the resident's preferences was left blank. On the day of the incident, staff observed a Registered Nurse (RN) yelling at the resident and mimicking their behavior, rather than using the calm approach specified in the care plan. Multiple staff statements indicated that the RN's actions escalated the resident's agitation, leading to a disruptive situation where both the RN and the resident were yelling at each other. Interviews with staff revealed that the resident, who has dementia, was triggered and became increasingly agitated when their desire to go outside was not accommodated. Staff noted that the situation could have been defused by taking the resident outside, but this was not done due to a busy period. The care plan's interventions to distract and calm the resident were not effectively implemented, and the lack of documented resident preferences further limited the staff's ability to address the resident's needs appropriately during the incident.