Failure to Provide Individualized Dementia Care and Inadequate Behavioral Management
Penalty
Summary
Facility staff failed to provide high-quality, compassionate, and individualized care to a resident with dementia, as required by facility policy and best practices for dementia care. The staff did not adequately assess or address the root causes and triggers of the resident's behavioral symptoms, such as hoarding napkins and washcloths, aggression toward staff and peers, and repeated requests for snacks and fluids. Documentation repeatedly lacked evidence of staff attempts to identify antecedents or implement non-pharmacological interventions before resorting to medication changes. Instead, staff primarily used redirection, which was often ineffective, and escalated to antipsychotic medications without clear documentation of failed non-pharmacological strategies or thorough behavioral assessments. The resident, who had diagnoses of Alzheimer's, dementia, and anxiety, experienced a decline in well-being, including lethargy, weight loss, agitation, physical altercations, and new skin breakdown. Despite ongoing behavioral issues, staff did not consistently document or investigate potential triggers such as pain, hunger, thirst, boredom, or environmental factors. There was also a lack of individualized interventions, such as providing the resident with their own supply of napkins or addressing possible discomfort with toileting routines. The care plan was not updated to reflect ongoing behavioral changes or to include new strategies based on observed triggers and outcomes. Additionally, the facility's use of antipsychotic medications, including Seroquel, Haldol, and Risperidone, was not in accordance with approved indications for elderly residents with dementia. Orders for these medications were made without sufficient documentation of behavioral assessments or evidence that non-pharmacological interventions had been exhausted. The facility failed to follow its own dementia care policies, which emphasize person-centered care, regular review of care plans, and prioritization of non-pharmacological interventions. As a result, the resident's dignity, well-being, and independence were not adequately supported, and the unique challenges posed by dementia were not effectively addressed.