Failure to Implement Person-Centered Care Plan and De-Escalation for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and multiple mental health diagnoses, including major depressive disorder, anxiety disorder, and dementia. The resident's care plan identified a history of trauma and behavioral issues, such as aggression and wandering, and included interventions like positive interaction, de-escalation techniques, and contacting family during episodes of increased confusion or combativeness. However, the care plan lacked specific de-escalation techniques for staff to implement, and staff did not follow the existing interventions during a behavioral incident. On the day of the incident, the resident exhibited behaviors such as wandering into other residents' rooms, taking items, and becoming agitated when an item was removed from his possession. The situation escalated when the resident pushed a bedside table into a nurse, chased staff with a call light cord, and fell to the floor. Instead of following the care plan interventions, four staff members forcibly carried the resident by his extremities to his room and held the door closed, effectively restraining and isolating him without attempting de-escalation or removing other residents from the area as outlined in the care plan. Interviews with facility leadership and staff revealed that the staff did not attempt any de-escalation techniques and chose to restrain and seclude the resident because they believed it was easier than removing other residents from the area. The Director of Nursing and Administrator both stated that staff failed to follow the care plan and did not notify the resident's family as required. The resident's power of attorney was not informed of the incident or the use of restraint and seclusion until after the fact, and expressed that she should have been contacted earlier to help de-escalate the situation.