Failure to Develop and Document Individualized Care Plans for Residents with Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide timely and individualized care planning and documentation for residents diagnosed with dementia who displayed behavioral symptoms. Multiple residents with severe cognitive impairment and behavioral health diagnoses, such as dementia, anxiety, and PTSD, exhibited frequent behaviors including aggression, wandering, self-harm ideation, and verbal outbursts. The facility did not consistently develop or update care plans to address new or escalating behaviors, such as self-injurious actions or aggression toward others, nor did it incorporate non-pharmacological interventions recommended by psychiatric providers into the residents' care plans. Additionally, there was a lack of documentation regarding the effectiveness of interventions used to manage these behaviors, and behavioral incidents were not always reviewed by the interdisciplinary team (IDT). Observations and interviews revealed that staff often attempted redirection and reassurance, but these interventions were not always effective or documented in the clinical record. Behavioral incidents, such as physical altercations between residents, self-harm statements, and aggressive actions toward staff, were not consistently recorded in behavior monitoring tools or the medication administration record (MAR). In several cases, staff and family members reported that residents displayed behaviors almost daily, yet the clinical documentation did not reflect the frequency or nature of these incidents. Furthermore, the facility did not always provide adequate supervision, as evidenced by residents wandering into other rooms, attempting to leave the facility, or being left unsupervised in common areas. Staffing concerns were also noted, with multiple staff members and a visitor reporting that the dementia care unit was often understaffed, making it difficult to provide sufficient supervision and timely interventions for residents with behavioral health needs. The lack of adequate staffing contributed to an environment where resident-to-resident altercations and behavioral escalations occurred without prompt or effective intervention. The facility's own policy required person-centered, interdisciplinary care planning and accurate documentation of behavioral health needs, but these standards were not met for several residents during the survey period.