Failure to Provide Person-Centered Dementia Care and Timely Neurology Follow-Up
Penalty
Summary
A deficiency was identified when a resident diagnosed with severe dementia and cerebral ischemia did not receive appropriate treatment and services to maintain their highest practicable well-being. The resident exhibited frequent wandering, entered other residents' rooms, and engaged in behaviors that disrupted others, including tampering with medical equipment. In response, the facility moved the resident to a private room at the end of the hallway, but the resident had difficulty adjusting, continued to wander, and often returned to their previous room, sometimes dressing in other residents' clothing. The resident's new room was bare, lacking standard furniture and personal effects, and there was no evidence of person-centered interventions to personalize the environment or address the resident's cognitive and behavioral needs as outlined in the care plan. Following a hospitalization for altered mental status, hospital discharge instructions recommended a neurology follow-up for dementia management within one to two weeks. However, there was no documented evidence that a neurology consult was ordered or scheduled after the resident's return to the facility. Staff interviews confirmed that the resident continued to display dementia-related behaviors, such as wandering and poor sleep, and that interventions were limited to group activities, occasional one-on-one engagement, and attempts to provide tactile stimulation. The resident did not have access to a personal music device, despite documented preferences, and there was no evidence of individualized interventions to address their early morning routines or other specific needs. The interdisciplinary team discussed transferring the resident to a specialized dementia unit, but no facility accepted the resident. Staff and leadership interviews revealed a lack of awareness or implementation of care plan interventions tailored to the resident's habits and preferences. The facility's actions did not align with its own dementia care policy, which required identification of the neurological basis of dementia and development of a resident-centered care plan to maximize quality of life.