Failure to Provide Individualized Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to ensure that three residents diagnosed with dementia received appropriate, individualized treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. For these residents, care plans were not sufficiently personalized or updated to reflect their specific behavioral symptoms and needs. The facility's policies referenced behavior monitoring and social work responsibilities, but there was no policy provided regarding dementia care or the dementia care unit when requested. Staff education materials on dementia were general and did not translate into individualized interventions for the residents reviewed. One resident with a history of stroke, dementia, and depression exhibited repeated sexually inappropriate and aggressive behaviors toward other residents, including entering other residents' rooms, undressing, and making inappropriate physical contact. Despite multiple incidents documented in nursing notes and staff interviews, there was no evidence of follow-up from behavioral health or social services, nor were care plan interventions updated to address these behaviors. Staff reported that interventions such as alarm mats were ineffective, and the resident was able to bypass or disable them. The care plan contained generic interventions and lacked specific, personalized strategies to address the resident's behavioral symptoms and memory impairment. Another resident with early-onset Alzheimer's disease and a history of agitation and psychotic disorder displayed frequent verbal and physical aggression, wandering, and inappropriate behaviors, including threats toward others. Nursing notes documented multiple behavioral incidents, but care plan updates and social work follow-up were lacking or delayed. Staff interviews indicated that interventions were not consistently effective or individualized, and documentation of non-pharmacological interventions was insufficient. A third resident with dementia and depression exhibited yelling out and agitation, but care plans and interventions were not personalized, and there was no documented social work reassessment following behavioral episodes. Across all three cases, the lack of timely, individualized care planning and follow-up contributed to the deficiency.