Failure to Implement Comprehensive Care Plan for Resident with Advanced Dementia
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident with advanced dementia. Observations revealed that the resident was repeatedly found in unsafe situations, such as rummaging through other residents' property, leaning forward in her wheelchair close to falling, and attempting to pick up objects from the floor without staff intervention. Staff did not redirect the resident, offer diversional activities, or provide necessary supervision as outlined in her care plan. The care plan specified interventions such as redirection, behavioral interventions, monitoring whereabouts, encouraging participation in activities, and observing for safety concerns, but these were not observed in practice. Interviews with staff confirmed that the resident exhibited wandering and crying behaviors, which sometimes led to negative interactions with other residents. Staff reported attempting to manage these behaviors with medication and by closing other residents' doors, but did not consistently implement non-pharmacological interventions or provide diversional activities as required by the care plan. The lack of adherence to the care plan resulted in the resident being at continued risk for falls and behavioral incidents, with staff failing to anticipate or address her needs as documented.