Failure to Address and Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to identify, address, and adjust care needs for five residents who exhibited dementia-related behaviors or were negatively impacted by such behaviors. One resident with a history of Neurocognitive Disorder with Lewy Bodies demonstrated severe cognitive impairment and exhibited behaviors such as yelling, wandering, and sexually inappropriate actions, as documented on behavior monitoring forms. Despite these documented behaviors, no interventions were added or recorded, and the resident's care plan and Kardex lacked any mention of these behaviors or guidance for staff on how to manage them. Other residents were directly affected by these deficiencies. Two cognitively intact residents reported that the resident with dementia repeatedly entered their room uninvited, with one incident involving urination on a bed and another involving an attempted sexual contact. Both residents expressed anger, frustration, and helplessness, and staff interviews revealed a lack of awareness or investigation into these incidents. Staff relied on the Kardex for intervention guidance, but it did not provide any relevant information for managing the behaviors. Another resident with dementia and behavioral disturbances was documented as frequently yelling, screaming, and exhibiting aggressive behaviors such as kicking, hitting, grabbing, and using abusive language. These behaviors were noted by staff and affected nearby residents, one of whom reported significant distress and sleep disruption. However, the care plan for this resident only addressed medication interventions and did not include strategies for managing the documented behaviors. Staff confirmed that the care plans and Kardexes did not provide adequate or person-centered interventions for these residents' behavioral needs.