Failure to Follow Care Plan and Professional Standards for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, major depressive disorder, anxiety disorder, and dementia was dependent on staff for activities of daily living and exhibited behaviors such as screaming and resistance during care. The resident's care plan included specific interventions for managing care-resistant behavior, such as using calm, soft tones, avoiding escalation, and employing person-centered approaches to ensure the resident felt safe and respected. Despite these directives, two CNAs failed to follow the established plan of care during an incident in which they attempted to change the resident's incontinence brief. Video evidence provided by the resident's family showed the CNAs engaging in physically rough handling, including pushing the resident's head down, restraining his chest, and removing clothing in a swift and rough manner, which caused the resident to shriek audibly and appear visibly frightened. One CNA was observed slapping the resident's face after telling him to stop screaming. The care was continued despite the resident's clear distress, and no nursing supervisor was called during the incident. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap captured in the video. Interviews with the involved CNAs revealed a lack of specific training on managing dementia-related behaviors and de-escalation techniques. One CNA stated she did not receive training specific to the resident or dementia care, and both CNAs did not recognize the resident's resistance as a behavioral issue requiring specialized intervention. The DON and other staff acknowledged that the actions did not meet the facility's standards, but did not classify them as abuse. The incident demonstrated a failure to provide care in accordance with professional standards and the resident's individualized care plan.