Failure to Identify and Address Resident Behavioral Disturbances
Penalty
Summary
The facility failed to identify and address a resident's behavioral disturbances, specifically incidents of hitting and yelling at staff and other residents. Observations, interviews, and record reviews revealed that the resident, who had diagnoses including late-onset Alzheimer's disease and cerebral infarction, exhibited behaviors such as wandering, entering other residents' rooms, yelling, and attempting to hit others with her cane. Despite these behaviors being observed and reported by staff, there was no care plan in place addressing these issues prior to a documented altercation. The Minimum Data Set (MDS) assessment completed for the resident did not reflect any behavioral symptoms, and the social service assistant responsible for the MDS did not interview staff or have knowledge of the resident's behaviors. Further review showed that behavior monitoring was only ordered for a short period after an altercation occurred, and there was no ongoing monitoring or comprehensive assessment of the resident's behavioral symptoms prior to the incidents. The facility's policy required staff to evaluate behavioral symptoms as part of the comprehensive assessment and to develop a care plan accordingly, but this was not done in this case. Interviews with staff confirmed that the resident's behaviors should have been identified and care planned to ensure appropriate care and safety.