Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with dementia and severe cognitive impairment. Clinical record review showed that the resident had a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment. Despite facility policy requiring appropriate treatment and services for residents with dementia, the care plan for this resident did not address their dementia or cognitive loss. Interviews with facility staff revealed confusion regarding responsibility for developing dementia care plans. The Registered Nurse Assessment Coordinator stated that Social Services was responsible, while the Social Worker was unaware of this responsibility and believed it was the RNAC's duty. Both confirmed that no individualized care plan addressing dementia and cognitive loss had been developed or implemented for the resident.