Failure to Provide Person-Centered Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with unspecified dementia, agitation, depression, anxiety disorder, and visual hallucinations. The resident exhibited significant behavioral symptoms, including aggression, resistance to care, verbal and physical altercations with staff and other residents, and sexually inappropriate behaviors. Despite these ongoing issues, the facility did not conduct a comprehensive assessment to identify the root causes or triggers of the resident's behaviors, nor did it develop or implement a person-centered care plan with individualized, non-pharmacological interventions. The care plan lacked specific interventions tailored to the resident's needs, and staff were not provided with adequate guidance or training to manage the resident's complex behaviors. Documentation in the Treatment Administration Records (TAR) was inconsistent and incomplete, with staff failing to accurately monitor or record the resident's behaviors as required. Staff interviews revealed a lack of understanding regarding the resident's hallucinations and behavioral symptoms, and there was no evidence of a root cause analysis being performed to address the behavioral changes. The facility's approach to supervision was insufficient, as 1:1 supervision was expected to be provided by staff already assigned to the unit, rather than by a dedicated staff member, resulting in inadequate monitoring and intervention during behavioral incidents. Additionally, staff on the dementia unit had not received specialized dementia training, and there was high turnover among staff, further impacting the quality of care. Multiple staff members reported feeling unsupported and overwhelmed, with insufficient resources to provide the required supervision and care. The facility did not investigate incidents or provide staff with the necessary tools to implement person-centered interventions, and the care plan failed to identify or address environmental triggers that may have contributed to the resident's behavioral expressions.