Failure to Provide Appropriate Dementia Care and Use of Unauthorized Restraint
Penalty
Summary
A resident with a diagnosis of Alzheimer's disease and other forms of dementia was admitted for a short-term respite stay. The resident had a known history of wandering but no prior physically aggressive behavior. On the evening in question, staff attempted to assist the resident with bedtime care, which the resident resisted, stating that only their spouse performed such care. The resident became increasingly agitated, expressed a desire to leave the facility, and attempted to exit through multiple doors. In response to the resident's attempts to leave, multiple staff members pursued the resident throughout the facility, physically blocked exit doors from both inside and outside, and put hands on the resident to prevent elopement. These actions escalated the resident's agitation and resulted in the resident becoming physically aggressive, injuring several staff members. Law enforcement was called, and upon arrival, the resident reported feeling attacked by numerous individuals. Staff interviews and record reviews revealed that staff did not follow the facility's own policies and training regarding the management of agitated or wandering residents, which emphasize the use of least restrictive measures, avoiding physical restraint, and not blocking exits. The facility's care plan for the resident included specific interventions for wandering and agitation, such as approaching from the front, avoiding overstimulation, providing reassurance, and maintaining a calm environment. However, these interventions were not followed during the incident. Staff actions, including physically restraining the resident and blocking exits, were inconsistent with both the care plan and facility policies. Post-incident interviews indicated that some staff were not adequately trained on managing severe agitation or elopement, and there was a lack of immediate post-incident education for all involved staff.