Failure to Implement Care-Plan Interventions for Dementia-Related Behaviors
Penalty
Summary
The facility failed to implement individualized, person-centered interventions as outlined in the care plan for a resident diagnosed with severe dementia. The resident, who was admitted with a diagnosis of dementia and assessed as severely cognitively impaired with a BIMS score of 3, had a care plan in place to address behaviors such as yelling out and resistance with care. The care plan specifically directed staff to approach the resident calmly and, if the resident became agitated, to stop the activity and re-approach later when the resident was calmer. On the evening in question, two nurse aides were providing care when the resident became combative and screamed. Another staff member reported hearing a muffled voice and suspected inappropriate staff intervention, though the facility's investigation did not substantiate abuse. Despite the lack of evidence for abuse, documentation and staff interviews confirmed that the care-planned dementia interventions were not implemented during the incident. There was no evidence that staff stopped care and re-approached the resident as directed by the care plan when the resident became agitated. The Assistant Director of Nursing and the Corporate Nurse Consultant both confirmed that the individualized interventions for dementia-related behaviors were not followed for this resident.