Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with dementia. Despite the facility's policy requiring the interdisciplinary team to create and adjust resident-centered care plans for individuals with confirmed dementia, record review showed that no such care plan addressing dementia care needs was in place for this resident. The resident, admitted with diagnoses including unspecified dementia, major depressive disorder, and psychotic disorder, was assessed as having severe cognitive impairment and non-Alzheimer's dementia. Observations over several days revealed that the resident remained in bed awake without engagement, and interviews with the resident's roommate indicated that the resident was not provided with activities or engagement opportunities. Multiple staff members, including nurses and the DON, confirmed that each resident with dementia should have a specific care plan tailored to their needs, and acknowledged that this was not done for the resident in question.