Failure to Develop and Implement Behavior Care Plan for Resident with Dementia
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive behavior care plan for a resident with a diagnosis of dementia and behavioral disturbances. Despite multiple nursing and respiratory progress notes, as well as staff interviews, documenting the resident's repeated refusals of care, expressions of wanting to go home, crying, yelling, and other behavioral symptoms, there was no documented evidence of a behavior care plan in the resident's records. The facility's policies require individualized, person-centered care plans and assistance with activities of daily living according to each resident's needs, but these were not followed in this case. The resident was noted to be moderately cognitively intact, used a wheelchair, required varying levels of assistance with daily activities, and was on multiple psychotropic medications. Staff interviews confirmed ongoing behavioral issues, including refusal of care, yelling, and expressions of distress, which were reported verbally to nursing staff but not formally documented in the electronic medical record or addressed through a care plan. The Director of Nursing acknowledged that a behavior care plan was not in place and that behaviors were only being documented in nursing progress notes.