Failure to Address Dementia Care and Medication Refusals Leads to Escalating Behaviors
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in a deficiency. The resident, an elderly female with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, major depressive disorder, and insomnia, was admitted to the facility and exhibited ongoing medication refusals for her prescribed dementia and psychotropic medications. Despite repeated refusals documented in the Medication Administration Record (MAR) and nursing notes, there was no evidence that the facility adequately addressed these refusals or implemented effective interventions. The care plan did not address the resident's medication refusals or provide individualized behavioral interventions related to her dementia diagnosis. Throughout her stay, the resident displayed escalating behaviors, including aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed that medication refusals were a persistent issue, with some staff reporting that the resident had never taken medications from them and that her compliance was unpredictable. Although staff documented refusals and some behavioral incidents, there was a lack of timely notification to the physician and family, and no consistent follow-up or adjustment of interventions was documented. The resident's family was not informed of the ongoing medication refusals, and the psychiatric provider was not involved in a timely manner, with only one documented visit after admission and no clear evidence of ongoing psychiatric oversight. The resident's behaviors escalated to the point of physical aggression towards another resident, leading to her transfer to an inpatient psychiatric hospital for further evaluation. The facility's own policy required individualized, person-centered interventions and involvement of the interdisciplinary team and family in care planning, but these steps were not adequately followed. The deficiency was identified as Immediate Jeopardy due to the facility's failure to ensure the resident received necessary treatment and services to maintain her highest practicable well-being, as evidenced by untreated dementia symptoms, behavior escalation, and lack of appropriate care planning and communication.
Removal Plan
- All residents on dementia medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
- The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
- All residents with a diagnosis of dementia and/or require psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Interventions will also include pharmacological and non-pharmacological approaches to care. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
- The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The orders will include monitoring for any changes in condition after refusals. The care plan will be updated by DON, ADON, MDS or designee.
- The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director.
- Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days for dementia medications, increased or escalating behaviors.
- Dementia/Behavior Health Policy: Importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care.
- Care Plan Policy: All residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors.
- The medical director was notified of the immediate jeopardy citation by the administrator.
- An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
- In-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment.
- Monitoring the Plan of Removal implementation occurred through daily onsite visits. Facility monitoring activities included review of 24-hour reports, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and repeated resident-to-resident altercations was not comprehensively reassessed after multiple incidents, and the record did not show identification of triggers or updated individualized interventions. Staff described ongoing pillow-taking, room changes, and aggression, but the care plan was not documented as revised. In addition, another resident with severe cognitive impairment and Huntington’s disease was observed repeatedly running barefoot and agitated while staff did not consistently follow the care plan’s interventions such as footwear, ambulation, redirection, snacks, or a calm environment.
Staff failed to appropriately respond to dementia-related behaviors for multiple residents. A resident on a locked memory care unit repeatedly exit-seeked and became aggressive when prevented from going outside, while staff relied on redirection and PRN meds after escalation. Another resident was loudly scolded in the dining room after taking silverware, and a third resident was moved to a med room after wandering into female rooms and undressing, with staff reportedly telling him not to hit them and escalating his behavior. Care plans and notes did not show consistent individualized behavioral management.
A resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance had trazodone reduced from 50 mg to 25 mg after a pharmacy review. Staff later documented increased anxiety, insomnia, wandering, and agitation, and psychiatry recommended increasing trazodone back to 50 mg or even 75 mg nightly, but no order was entered and the resident continued receiving 25 mg. Interviews confirmed the psychiatric recommendation was missed and not addressed.
A resident with Parkinson’s disease, dementia, and major depressive disorder did not have an individualized, person-centered dementia care plan included in the comprehensive care plan. The RNAC confirmed the dementia diagnosis and that the facility failed to develop and implement a dementia care plan for the resident.
A resident admitted with dementia had a care plan that listed only general interventions such as cueing, reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show an individualized person-centered care plan addressing the resident’s specific cognitive loss and dementia-related needs, and the findings were reviewed with the NHA and DON.
A resident with Parkinson’s disease and dementia had documented wandering risk and prior behaviors of entering other residents’ rooms and beds, but the facility did not have a care plan addressing those behaviors before the incident. Staff found the resident in another resident’s bed with his genitals exposed and the other resident’s breast exposed. Interviews showed the assigned 1:1 sitter did not know why supervision was needed, the nurse was unaware of prior behaviors, and the DON reported the IDT typically identifies triggers and interventions, but no documentation showed that this occurred before the event.
Failure to Reassess Dementia Behaviors and Follow Care Plan Interventions
Penalty
Summary
The facility failed to provide appropriate dementia care treatment and services for a resident with moderate cognitive impairment, dementia, anxiety, insomnia, wandering, and rejection of care. The resident’s care plan identified repetitive questions, wandering into other residents’ rooms, and involvement in resident-to-resident altercations as a victim, with interventions such as psychology follow-up, monitoring and documenting mood and behavior, calm approach, removal from crowded areas, one-to-one visits, and introduction to residents with similar interests. The record also noted use of a different colored pillow for forgetfulness and reminders for staff to prompt the resident to carry the special pillow when seen with a white pillow. After repeated resident-to-resident altercations, including incidents in which the resident struck a roommate, fought with another resident over a pillow, slapped a resident in the dining room, and later kicked and hit another resident before being sent to the ER, the medical record did not show that staff reassessed the underlying causes of the behaviors, evaluated whether prior interventions were effective, identified behavioral triggers, or revised the care plan with new individualized interventions. Staff interviews described that the resident wandered with a pillow, took other residents’ pillows, and was moved from room to room after conflicts, but documentation of a comprehensive updated plan of care was not provided. The facility also failed to follow established dementia care interventions for another resident with severe cognitive impairment and Huntington’s disease who had verbal behaviors, agitation, running in the hallway, and physical aggression. The care plan and aide care sheet called for gripper socks or shoes, ambulation with the resident, a calm and quiet environment, reduced noise, snacks or food when agitated or running, wheelchair use when needed, and redirection. During observations, the resident repeatedly ran barefoot through the hallway and in and out of the room, while staff did not provide footwear, walk with the resident, redirect her to slow down, or consistently implement the planned interventions. The dining room television was also observed playing violent scenes at a volume loud enough to interfere with conversation despite the care plan calling for reduced environmental stimulation and a calm environment.
Staff Failed to Respond Appropriately to Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure staff knew how to appropriately respond to, assess, and address behavioral symptoms in residents diagnosed with dementia. The report identifies three residents with dementia-related behaviors who were managed primarily through staff redirection, verbal correction, or PRN medication, rather than through consistent individualized behavioral approaches described in their care plans and the facility’s dementia care policy. One resident, who had dementia and agoraphobia with panic disorder and lived on a locked memory care unit, repeatedly wandered and attempted to exit through doors leading to an enclosed outdoor area. When she became upset and aggressive after being prevented from going outside, multiple staff members responded, and a nurse sought PRN medication to calm her down. Staff statements indicated they usually did not let her go outside or walk with her even though the area was available, and that they relied on PRN medication when she became upset. Her progress notes documented repeated aggressive and exit-seeking behaviors, and her care plan listed wandering and verbal aggression interventions, but the observed response centered on containment, redirection, and medication after escalation. Another resident with dementia and anxiety was observed in the dining room taking silverware from the table and wrapping it in a napkin and placing it in his shirt. A nurse responded in a loud, stern voice, repeatedly telling him not to do it and stating that all new silverware was needed because of him. The resident’s progress notes did not document this behavior, and his care plan did not address the specific utensil-taking behavior. A DON later stated the resident needed to be spoken to calmly because otherwise it would work him up more. A third resident with dementia was reported by his sister and staff to be wandering into female residents’ rooms, trying to remove his clothes, and becoming aggressive. Staff moved him to the medication room and told him not to hit staff, which reportedly escalated his behavior. The sister stated staff seemed shocked by his wandering despite his dementia and believed they lacked training on how to handle the behavior. The resident’s progress notes documented wandering into female peers’ rooms, undressing, and becoming combative, while his care plan addressed general behavior issues with calm approach, diversion, and removal from the situation, but the events described showed staff responses that were loud, reactive, and not aligned with those approaches.
Psychiatric trazodone recommendation not implemented for resident with dementia and wandering
Penalty
Summary
The facility failed to address psychiatric NP recommendations to increase trazodone for a resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance. The resident was admitted with diagnoses that included dementia, anxiety, restlessness, and agitation, and had a documented pattern of exit-seeking, wandering, refusing medications, and requiring 1:1 supervision. Trazodone had initially been ordered at 50 mg at bedtime, then reduced to 25 mg after a pharmacy recommendation for gradual dose reduction was accepted by the NP. After the dose was reduced, an NP progress note documented that staff reported increased anxiety and insomnia and that the resident had failed the dose reduction, but the order remained at 25 mg at bedtime. The record showed no new order to increase trazodone back to 50 mg at that time. Nursing notes later documented ongoing wandering throughout the night, the resident entering another resident’s room, being found in another resident’s bed, and becoming agitated and combative when redirected. The care plan continued to identify behavioral symptoms including restlessness, anxiety, agitation, wandering, and exit-seeking. A psychiatric assessment noted significant cognitive and behavioral challenges, agitation, suspicious behavior, and a history of violent behavior, and indicated medication management services were needed. A psychiatric follow-up later recommended increasing trazodone to 50 mg or 75 mg nightly for sleep and restlessness, but the MAR showed the resident continued to receive 25 mg nightly and no corresponding order was found. Interviews with the Clinical Coordinator, NP, Psychiatric NP, and DON confirmed that the psychiatric recommendation to increase trazodone was missed and not addressed, and the NP stated it was her error and that she thought the medication had been discontinued completely.
Missing Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan to address dementia for Resident R20. The facility policy on comprehensive care plans stated that each care plan should include measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and should describe the services and care to be furnished to attain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident R20 was admitted to the facility and the MDS indicated diagnoses of Parkinson’s disease, dementia, and major depressive disorder. Review of the clinical record showed that the resident’s care plans did not include a care plan for dementia. During interviews, the RNAC confirmed that Resident R20 had a diagnosis of dementia and that a dementia care plan was not included in the comprehensive care plans, and also confirmed that the facility failed to develop and implement an individualized person-centered care plan to address dementia for this resident.
Failure to Individualize Dementia Care Plan
Penalty
Summary
Failure to provide appropriate treatment and services for dementia was identified for Resident 11, who was admitted on April 3, 2026 with a diagnosis including dementia, described as loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life. Review of the resident’s current care plan for impaired cognitive function/dementia or impaired thought processes related to dementia showed only general interventions such as cueing and reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show that the facility had implemented an individualized person-centered care plan to address the resident’s specific dementia and cognitive loss needs. The findings were reviewed with the NHA and DON on June 17, 2026 at 12:10 PM.
Failure to Address Dementia-Related Wandering and Inappropriate Bed Entry
Penalty
Summary
The facility failed to implement effective interventions for a resident with dementia-related behaviors in a timely manner. The resident, who had diagnoses including Parkinson’s disease and dementia, was documented as being at risk for wandering on wandering risk assessments, and prior progress notes described him urinating in his hat and garbage can, sitting in another resident’s bed, and becoming agitated when redirected from another resident’s room. Despite these documented behaviors and collateral information noting a history of wandering and searching behaviors related to his deceased spouse, there was no care plan addressing the resident’s known wandering risk until after the incident in which he was found in another resident’s bed. On the day of the incident, staff found the resident in another resident’s bed under the covers with the other resident. The resident was undressed from the waist down, his genitals were exposed, and the other resident’s breast was exposed. The resident stated he did not know what happened and did not remember, and when asked why he took off his brief, he said it was dirty. The record also showed that the resident had been moved to a new room on the second floor, but there was no documentation explaining why the room change was made. Interviews with staff showed that the CNA who was assigned as a 1:1 sitter did not know why the resident required that supervision and believed it may have been because he wandered into other residents’ rooms. The nurse assigned to the resident reported being unaware of prior wandering or sexual behaviors, although she had heard reports that he wandered into other residents’ rooms. The DON stated the resident was placed on the second floor and that the IDT typically identified triggers and interventions for wandering behaviors, but no documentation was found showing the IDT monitored the resident’s wandering pattern or identified triggers before the incident. The facility’s behavioral management policy stated that the IDT would identify causes of behavior changes, document and track behaviors, and address behaviors and interventions in the care plan.
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