Failure to Address Dementia Care and Medication Refusals Leads to Escalating Behaviors
Penalty
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.