Failure to Provide Individualized Dementia Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate dementia care and services to a resident diagnosed with vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder. The resident exhibited ongoing and escalating behaviors, including aggression towards staff and other residents, wandering, and verbalizations of self-harm and suicidal ideation. Despite these behaviors, the facility did not adequately assess, identify, record, or respond to the resident's specific behavioral triggers, nor did they reassess and update the care plan with individualized interventions tailored to the resident's needs. The care plan lacked resident-specific strategies for managing behaviors and triggers, and staff interventions were often ineffective. Documentation in the resident's medical record revealed multiple instances where the resident displayed aggressive and unsafe behaviors, such as attempting to strike staff, refusing care, wandering, and making statements about wanting to die. Staff frequently attempted verbal redirection, which was documented as ineffective in many cases. There were also several occasions where the facility failed to notify the resident's provider or representative of significant behavioral changes, including suicidal statements and increased agitation following medication changes. The facility's own policy required individualized, person-centered care plans and prompt notification of changes in condition, but these were not consistently followed. Interviews with staff confirmed that the care plan did not include resident-specific interventions for dementia and that triggers for behaviors were not identified. Staff reported increased behavioral issues after medication changes, including aggression and sleep disturbances, but provider notifications were not always documented or made. The facility's deficient practice resulted in ongoing harm, as the resident's behaviors escalated without effective intervention, ultimately leading to the resident's transfer to the hospital for further evaluation and care.