Failure to Develop Person-Centered Care Plan and Provide Individualized Dementia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and was at risk for elopement. The care plan lacked specific dementia-related interventions and relied primarily on nonspecific redirection strategies. Staff interviews revealed that key team members were unaware of the full extent of the resident's behaviors, such as constant wandering, and therefore did not include appropriate interventions in the care plan. The care plan did not provide measurable or detailed actions for staff to follow, and interventions were often generic or unrealistic given the resident's cognitive status. Record reviews showed that the care plan did not address the resident's pain management needs, as interventions for pain in the right knee were missing, and pain goals were not individualized or specific to the resident's condition. The plan for cognitive decline included unrealistic goals, such as developing coping skills, despite severe cognitive impairment. Interventions for falls, elopement, and aggressive behaviors were vague, lacked specificity, and did not reflect the resident's actual patterns or needs. For example, the falls care plan did not address the resident's weakness, confusion, or poor safety awareness, and did not specify which items should be kept within reach or how to anticipate the resident's needs. Additionally, the facility failed to provide meaningful activities for residents in the memory care unit, as reported by both family and staff interviews. The care plan for elopement risk referenced offering preferred activities, but none were listed, and interventions were generic and not tailored to the resident. The lack of individualized, person-centered interventions and activities resulted in staff lacking clear guidance to effectively meet the resident's needs, leading to inconsistent and potentially unsafe care, as well as unmet psychosocial needs for multiple residents.