Failure to Implement and Document Effective Behavioral Interventions for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, specifically by not ensuring an effective behavioral care plan, behavior monitoring, and documentation. The resident in question had a history of physical altercations with other residents, particularly when other residents wandered into her room. Despite multiple incidents where the resident physically struck peers, resulting in injuries such as bruises and a skin tear, there were no changes made to her care plan or interventions implemented to prevent further altercations. Staff were aware of these incidents and expressed concern for the safety of other residents, but no specific safety measures or interventions were documented or put in place. The resident's clinical record indicated diagnoses of dementia, psychotic disorder with delusions, depression, and sleep disorder, with moderately impaired cognition and a history of physical behaviors towards others. Behavior tracking forms only monitored aggressive behaviors towards staff, not towards other residents, despite documented incidents of aggression towards peers. The care plan included general interventions for mood issues and confusion but did not address the specific risk of resident-to-resident altercations. Additionally, the CNA care sheet noted the resident was combative and at high risk for falls but did not specify interventions to prevent altercations with other residents. Interviews with staff and the Social Services Designee revealed that the facility's policy required documentation and interdisciplinary review of new dangerous behaviors, but this process was not followed. The Interdisciplinary Team did not document meetings or evaluations after new behaviors were identified, and the Social Services Designee was unaware of several altercations and injuries. As a result, the facility did not implement or document effective interventions to address the resident's aggressive behaviors towards other residents, nor did it ensure ongoing monitoring and care plan updates as required by policy.