Failure to Implement Dementia Care Interventions and Supervision
Penalty
Summary
The facility failed to provide appropriate services, treatment, and interventions for a resident diagnosed with Alzheimer's disease and dementia, who exhibited significant cognitive and functional decline. The resident displayed frequent physical and verbal behaviors, including crying, yelling, wandering, and making statements indicating pain, fear, and distress. Despite these behaviors, staff did not implement the care-planned interventions such as providing diversional activities, one-to-one support, or prompt redirection when the resident was upset. Observations showed the resident calling out for help, expressing fear, and making statements about not wanting to live, without staff intervention or support. Interviews with staff revealed that the resident required constant supervision and had a history of altercations with other residents. Staff acknowledged that there was insufficient supervision and that activities for dementia care were lacking or only recently initiated. Documentation showed that the resident participated in very few activities over a two-month period, despite care plan interventions specifying the need for engagement in activities of interest and avoidance of overstimulation. Staff also failed to monitor and intervene during verbal altercations between residents, as required by the care plan. Review of the resident's health records and Minimum Data Set (MDS) assessments indicated severe cognitive impairment, increased behavioral symptoms, and a decline in functional abilities. The resident was unable to complete mood interviews, and staff assessments were either incomplete or blank. The care plan identified the resident as being at risk for verbal abuse from others due to her behaviors, yet the documented interventions were not consistently implemented, resulting in unaddressed distress and behavioral symptoms.