Failure to Provide Adequate Supervision and Individualized Dementia Care
Penalty
Summary
A resident with severe dementia, poor safety awareness, and a history of aggressive behaviors and wandering was admitted to the memory care unit. The resident exhibited continuous wandering, entered other residents' rooms, displayed aggression, and had multiple falls, some resulting in significant injuries such as a hip fracture and a compression fracture. Despite being identified as high risk for elopement and falls, the resident was not consistently provided with individualized interventions or adequate supervision to address her specific behavioral and safety needs. Documentation showed that staff were often unaware of her whereabouts, and interventions such as 1:1 observation were implemented only temporarily and not maintained, even though staff reported these measures were effective in ensuring safety. The care plans developed for the resident were not sufficiently individualized or tailored to her needs. Goals set for the resident, such as developing coping skills for cognitive decline, were unrealistic given her severe cognitive impairment. Interventions lacked specificity, and there was no clear plan for managing her pain, which may have contributed to her behaviors. The care plan also failed to identify patterns in her wandering or provide detailed strategies to prevent her from entering other residents' rooms. Staff interviews revealed a lack of consistent use of visual cues or other non-pharmacological interventions, and staff expressed concerns about insufficient staffing and supervision. Additionally, the facility failed to consistently administer pain medications as ordered, which was noted by the provider as a concern and may have contributed to the resident's ongoing agitation and behavioral issues. Monitoring tools, such as 15-minute checks, were not completed as required, and documentation was often incomplete or inaccurate. The lack of adequate supervision and oversight resulted in repeated incidents where the resident intruded into other residents' rooms, leading to altercations and injuries, and caused distress and fear among other residents. The facility's actions and inactions did not meet the resident's behavioral, safety, and cognitive needs as required.