Failure to Provide Individualized Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia who exhibited behavioral symptoms, including wandering, exit-seeking, entering other residents' rooms, and yelling out. For one resident with encephalopathy and non-Alzheimer's dementia, the care plan did not specifically address exit-seeking behaviors, sundowning, or times of increased behaviors, despite repeated incidents of elopement, wandering into other residents' rooms, and taking belongings. Documentation showed frequent refusals of medication and care, but these refusals were not addressed in the care plan. Staff interventions were limited to redirection and the use of stop signs on doors, which were inconsistently applied and not always effective in preventing the resident from entering other rooms or taking items. Multiple progress notes and interviews with staff and other residents confirmed ongoing issues with the resident's behaviors, including distress caused to peers when the resident entered their rooms, sat on their beds, or took personal items. The care plan did not include individualized interventions to prevent the resident from entering other rooms or address the removal of belongings. Staff and residents reported that the use of stop signs was inconsistent, and redirection was not always successful in mitigating the behaviors. The facility's policies required an interdisciplinary approach and person-centered care planning, but these were not fully implemented for this resident. For the second resident with dementia, the care plan addressed some behaviors such as fidgeting and restlessness but did not include targeted interventions for frequent yelling out, which was documented in progress notes and behavior monitoring. The yelling out caused distress to roommates and other residents, as confirmed by interviews. There was no evidence of a detailed assessment or individualized interventions for this behavior in the clinical record. The facility did not ensure that care plans were updated to reflect the residents' current behavioral needs, nor did it implement comprehensive strategies to mitigate the adverse effects of dementia-related behaviors.