Failure to Provide Adequate Behavioral Health Services for Resident with Dementia
Penalty
Summary
A facility failed to ensure that a resident with severe dementia received appropriate behavioral health care and services to attain their highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including severe early onset Alzheimer's dementia with mood disturbance, anxiety, and major depressive disorder, exhibited significant cognitive impairment and behavioral symptoms such as wandering, intrusive behaviors, and increasing aggression. Despite these symptoms, the care plan lacked comprehensive, resident-centered interventions, particularly non-pharmacological strategies, and there was no evidence of a thorough assessment addressing the resident's wandering and behavioral issues. Documentation revealed ongoing behavioral incidents, including the resident entering other residents' rooms, touching belongings, urinating in inappropriate places, and escalating physical and verbal aggression toward staff and other residents. Staff notes indicated the resident was difficult to redirect, required frequent cueing, and became more agitated as the day progressed. Multiple staff interviews confirmed that interventions were limited to redirection and medication administration, with no documentation of attempted or implemented non-drug interventions or a behavioral care plan tailored to the resident's needs. The situation culminated in a serious incident where the resident physically assaulted a staff member and attempted to harm another resident, resulting in the police being called and the resident being arrested for aggravated assault. Interviews with facility leadership and staff confirmed gaps in documentation, assessment, and care planning, as well as a lack of clear communication and follow-through regarding behavioral interventions. The facility did not provide evidence of a systematic approach to managing the resident's behavioral health needs, contributing to the actual harm experienced.