Failure to Individualize and Revise Dementia Care Plan for Resident with Escalating Behaviors
Penalty
Summary
The facility failed to develop, revise, and consistently implement an individualized, person-centered care plan to address dementia-related behaviors for a resident with a history of cerebral infarct and alcohol-induced persisting dementia. The resident was moderately cognitively impaired and exhibited a sustained pattern of escalating behaviors, including verbal aggression, resistance to care, unsafe wandering, and entering other residents' rooms. The care plan included only broad and generic interventions, lacking specific, actionable strategies tailored to the resident's repeated aggressive behaviors and safety risks. Despite documentation over several months showing the resident ambulating independently during episodes of agitation, being verbally abusive, and having conflicts with roommates and visitors, the care plan was not revised to address these ongoing issues. Interventions primarily consisted of room changes, redirection, and brief calming measures, without evidence of meaningful updates to include dementia-specific strategies, environmental modifications, or structured interventions. Nursing documentation repeatedly noted the resident's inability to be redirected and disruptive behaviors affecting other residents and staff. The facility was unable to provide a Dementia Care Program or policy during the survey, and although staff education materials on dementia care were available, there was no evidence that this education was translated into individualized care planning or consistent implementation for the resident. Interviews with facility leadership confirmed the failure to revise and implement an effective care plan to address the resident's documented dementia-related behaviors.