Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered activities and interventions for a resident diagnosed with dementia. Specifically, the care plan for a resident with severe cognitive impairment did not identify individualized activities of interest or account for the resident's history of working as a CNA, friendly personality, or tendency to enter other residents' personal space. Despite staff interviews confirming that the resident enjoyed helping others, participating in crafts, going outside, and engaging in activities such as manicures and music, these preferences and behaviors were not reflected in the care plan prior to a documented incident. An incident occurred in which the resident, known for patting and rubbing other residents in a non-aggressive manner, startled another resident by patting him on the head. This led to the second resident, who was drowsy and leaning forward, reacting by striking the first resident, resulting in a skin tear. Staff confirmed that the resident had a pattern of getting into others' personal space and that not all residents liked to be touched. The lack of individualized, person-centered interventions and failure to address the resident's specific behaviors and preferences in the care plan contributed to the incident.