Failure to Provide Individualized Dementia Care and Timely MD Notification
Penalty
Summary
A resident with a diagnosis of dementia and major depressive disorder began exhibiting aggressive and resistive behaviors within the first two weeks of admission. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with resident-specific interventions to guide staff in managing these behaviors. The facility also did not consistently notify the resident's medical doctor (MD) of the increased and ongoing behavioral issues, as required by facility policy. Documentation shows that staff were aware of the behaviors, but no individualized behavioral interventions were added to the care plan until more than three months after the behaviors began. Throughout the resident's stay, staff documented several episodes where the resident was physically aggressive toward CNAs, refused care, and became agitated, particularly during nighttime hours. Despite these repeated incidents, there was no evidence that the interdisciplinary team discussed these behaviors in their behavior management meetings, nor was there documentation that the MD was informed in a timely manner. When staff did attempt to notify the MD via fax about the resident's escalating behaviors, there was no follow-up when the MD did not respond over the weekend, and the issue was not addressed until days later. The lack of timely communication and absence of a comprehensive, individualized care plan left staff without clear guidance on how to manage the resident's challenging behaviors. The situation escalated when a staff member, in response to the resident's agitation and resistance, yelled at the resident, physically restrained them by holding their shoulders down and shaking them, and used a blanket to restrain the resident in bed. This incident was witnessed by another staff member, reported to management, and resulted in the resident expressing fear of staff during subsequent interviews. The facility's failure to provide appropriate treatment and services, including the development and implementation of a behavior care plan and timely communication with the MD, directly contributed to the continuation and escalation of the resident's challenging behaviors, culminating in an incident of staff-to-resident abuse.