Failure to Initiate Behavior Care Plan for Resident with Dementia and Behavioral Disturbances
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address behavioral issues for one resident with a history of dementia, behavioral and mood disturbances, and severely impaired cognition. Despite multiple documented instances where the resident resisted or refused activities of daily living (ADL) care, was verbally abusive, non-compliant with redirection, and exhibited uncooperative and combative behaviors, there was no evidence that a behavior or resistive-to-cares care plan was in place prior to late March. Progress notes over several months detailed repeated refusals of care, non-compliance, and safety concerns related to the resident's actions. Interviews with facility staff confirmed that the responsibility for initiating and updating care plans lies with the nurse managers. The nurse manager assigned to the unit was new and had not yet identified or initiated a care plan for the resident's behavioral issues, despite ongoing documentation of such behaviors. The lack of a timely and appropriate care plan was not in accordance with the facility's policy, which requires the interdisciplinary team to review and update care plans at least quarterly and as needed based on the resident's condition.