Failure to Assess and Address Behavioral Causes in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident diagnosed with dementia by not adequately assessing or identifying the underlying causes of the resident's behaviors. The resident was involved in an incident where another resident hit her after she repeatedly opened and closed his door. Staff interviews revealed that there was no formal behavioral assessment process in place, and interventions were limited to working with the physician on medications or providing distractions such as drinks or outdoor time. Staff were unsure if interventions were documented, and the care plan lacked specific strategies for managing or anticipating the resident's behaviors. Record review showed that the resident was consistently wandering, entering other residents' rooms, and displaying combative behavior. The facility's root cause analysis did not identify underlying factors contributing to the behaviors or specify effective interventions. The care plan noted the resident as an elopement risk and wanderer but only listed general triggers such as age, disease, and smoking, without detailing actionable interventions for staff. As a result, the facility did not provide a comprehensive approach to address or prevent the resident's behavioral issues.