Failure to Timely Develop and Implement Individualized Care Plan for Resident with Dementia and New Behavioral Symptoms
Penalty
Summary
The facility failed to timely develop and implement an individualized plan of care for a resident diagnosed with dementia who began displaying new behaviors involving physical contact with peers. Specifically, a resident with severe cognitive impairment and a history of anxiety and insomnia exhibited behaviors such as grabbing other residents in the dining area and in his room. These incidents were documented in the clinical record and included multiple room changes due to incompatibility with roommates, as well as episodes of overstimulation and confusion in common areas. Despite these documented behaviors and the initiation of new medications to address anxiety and agitation, the clinical record did not contain a care plan addressing the new behaviors, the use of psychotropic medication, or the resident's anxiety and agitation. The deficiency was further evidenced by the lack of communication and education among direct care staff regarding the resident's history of making physical contact with peers. Interviews with CNAs revealed that they were not informed about the resident's behavioral history, even after several incidents had occurred. The facility's own policy required that care plans be initiated for any problematic or distressing behavioral expression and when a resident is receiving psychotropic medication for mood or behavior. However, the care plan for the resident did not address the new behaviors, the use of lorazepam, or the risk of agitation and aggression with roommates. Additionally, the facility's interdisciplinary team (IDT) met and reviewed the resident's behaviors, but failed to ensure that a care plan was promptly developed and implemented to address the specific behavioral issues. The lack of a timely and individualized care plan resulted in continued incidents involving physical contact with peers, room changes, and increased supervision, without a documented, proactive approach to managing the resident's behavioral health needs as required by facility policy.