Failure to Implement Behavioral Care Plan Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement care plan interventions related to behavioral management for a resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. The resident was care-planned as high risk for mistreatment and had documented behaviors of screaming and resistance during care, with specific interventions outlined to address these behaviors, such as speaking calmly, avoiding escalation, and taking steps to help the resident feel safe. Despite these interventions, two CNAs did not follow the care plan strategies during an incident where the resident was being changed. Video evidence provided by the resident's family showed the CNAs restraining the resident by pushing his head and chest down, removing clothing in a rough manner, and slapping the resident's face after he screamed in distress. The resident was visibly frightened, screamed audibly, and resisted care, but the CNAs continued the interaction without calling a nursing supervisor or stopping to address the resident's distress. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap observed in the video. Interviews with staff revealed a lack of specific training on managing the resident's behaviors or dementia care, with both CNAs unable to recall receiving relevant training or in-service education. The LPN who assessed the resident after the incident did so the following day and did not observe physical signs of injury. The DON and other facility leaders acknowledged that the actions did not meet facility standards but did not classify them as abuse. The resident was later observed to be withdrawn and non-verbal, with staff not engaging him in activities.