Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to provide appropriate, person-centered treatment and services to residents diagnosed with dementia, as evidenced by observations, record reviews, and staff interviews involving three residents. For one resident with mild neurocognitive disorder and behavioral disturbances, staff did not offer preferred activities listed in the care plan, such as arts and crafts, games, or outdoor activities. Instead, the resident was observed sitting idly at the nurse's station or wandering into other residents' rooms without effective person-centered interventions to prevent such behavior. Staff interviews revealed a lack of awareness regarding individualized dementia care planning, and interventions were limited to redirection or providing generic items like a busy board or Rubik's cube, which were not effective or tailored to the resident's preferences. Another resident with severe cognitive impairment and dementia was observed repeatedly calling for help without timely staff response and was left with a television playing in a language she did not understand for over an hour. The care plan indicated she enjoyed music, social events, and being outdoors, but these preferences were not addressed during the observed periods. Staff did not provide or encourage participation in meaningful activities, and the resident was often left idle or unattended, contrary to her documented needs and preferences. A third resident with severe cognitive impairment, behavioral disturbances, and a history of wandering was not provided with any person-centered activities during multiple observation periods. The care plan included general interventions such as redirection and monitoring, but lacked individualized approaches to address his dementia care needs. Staff interviews confirmed difficulties in engaging the resident in activities and a lack of Spanish-speaking activities, despite the resident's language abilities. The resident was also observed to be combative and was moved for safety reasons, but no specific, person-centered interventions were documented or implemented to address his behavioral and cognitive needs.