Failure to Revise Care Plan and Monitor Self-Injurious Behavior in Dementia Resident
Penalty
Summary
The facility failed to revise the care plan and adequately monitor a resident diagnosed with dementia who exhibited skin picking and scratching behaviors. The resident, who had diagnoses including Alzheimer's disease, chronic pain, depression, and dementia, was observed with quarter-sized, reddish areas with partially scabbed centers on both cheeks. Despite these visible injuries, there were no progress notes, assessments, or care plans referencing the areas on her cheeks or her picking/scratching behavior. Staff interviews revealed that the behavior had been noticed previously, but it was not documented or addressed in the resident's care plan. The Memory Care Facilitator, responsible for care planning, acknowledged that the resident's skin picking should have been included in her care plan. The DON and other staff confirmed that the behavior was observed but not documented, and the areas on the resident's cheeks were not assessed or treated as needed. Review of the facility's behavior monitoring reports and progress notes showed no documentation of the resident's self-injurious behaviors, despite staff being aware of the issue. The facility's policy required care planning and intervention for problematic behaviors, but this was not followed for the resident in question.