Failure to Identify and Address Dementia-Related Behaviors and Provide Staff Training
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest practical well-being for a resident with vascular dementia. Staff did not identify or document triggers that led to the resident's aggression and combativeness, nor did they implement or document non-pharmacological interventions to address these behaviors. During an incident, staff continued to provide incontinence care and transferred the resident using a sit-to-stand lift while the resident was actively combative, resulting in the resident sustaining skin tears. The care plan was not updated to reflect the resident's behavioral responses or to provide individualized interventions related to dementia care. Multiple staff interviews revealed that several CNAs and LPNs had not received dementia care training upon hire and lacked direction on how to manage the resident's aggressive behaviors. Some staff were unaware of how to access care plans, and others relied on verbal reports to learn about resident care needs. Staff also reported that the resident was only aggressive with certain staff members, particularly those of the same gender, but this information was not communicated to facility leadership or reflected in the care plan. The psychiatric nurse practitioner was not informed of the resident's behavioral issues, and the care plan coordinator acknowledged that the care plan should have been updated after the incident. The facility did not provide a dementia care policy when requested, and there was no evidence that staff had received or understood dementia care training. The lack of communication, training, and individualized care planning contributed to the failure to address the resident's behavioral symptoms and ensure staff were equipped to manage dementia-related behaviors safely and effectively.