Failure to Provide Dignified Dementia Care Results in Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate and dignified dementia care to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident required one-person assistance with activities of daily living (ADLs) and had care plans in place that emphasized respecting her right to refuse care, maintaining a calm environment, and not forcing her to complete tasks. Despite these documented approaches, three CNAs attempted to provide incontinence care while the resident was combative, resulting in the staff holding her wrists and arms. This led to significant bruising on both wrists and lower forearms, as confirmed by skin assessments and X-rays ordered due to complaints of pain. The incident was precipitated by the resident's refusal of care and escalating combative behaviors, including hitting, kicking, biting, and pinching. Staff attempted multiple comfort and redirection measures, but these were ineffective. Instead of discontinuing care and re-approaching later, as outlined in the care plan and facility training, the staff proceeded with care by physically restraining the resident's wrists. There was no documentation indicating that the nurse was notified of the resident's escalating behavior or that the situation required immediate intervention for safety. The medical record and investigation did not provide evidence that care could not have been delayed or that the resident was unsafe if care was postponed. Interviews with staff and review of facility policies confirmed that staff were trained to step away and re-approach residents who refused care, and that physical restraint or force was not an acceptable practice. The facility's abuse prevention policy and dementia care training both emphasized the importance of respecting resident rights and using non-physical interventions. Despite this, the staff involved did not follow these protocols, resulting in actual harm to the resident in the form of bruising and pain.