Failure to Revise Dementia Care Plan Based on Resident Behaviors
Penalty
Summary
The facility failed to comprehensively assess and revise the care plan for a resident diagnosed with dementia and behavioral disturbances. The resident, admitted with severe cognitive impairment as indicated by a BIMS score of 6, exhibited frequent behaviors such as kicking, yelling, rejecting care, and threatening or grabbing others on 16 out of 32 days. The care plan was revised to instruct staff to analyze and document triggers and de-escalation strategies, and to engage calmly with the resident before providing care. However, no additional behavior triggers were identified in the care plan despite ongoing behavioral incidents. Staff interviews and observations revealed that the resident's behaviors were influenced by the presence or absence of the spouse, with increased agitation when the spouse left and calmer demeanor during visits. Staff also noted that the resident was less resistive to care when the spouse was present and more likely to hit female caregivers if approached unexpectedly. The Social Services Director, responsible for the dementia care plan, relied primarily on her own observations and staff-initiated feedback, acknowledging that more comprehensive staff input was needed to address the resident's behavioral and dementia-related needs.