Failure to Protect Combative Dementia Resident From Injury During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dementia and known aggressive behaviors was cared for in a manner that prevented injury. The resident had multiple diagnoses including vascular dementia, major depressive disorder, cerebrovascular disease, chronic kidney disease, COPD, and benign prostatic hypertrophy, and was described as severely cognitively impaired, unable to communicate effectively, and often nonsensical in speech. On observation, the resident was noted to have a yellow, green, and purple bruise under the right eye, a small red spot with faint bruising on the chin, and a recently healed area on the upper lip. The resident’s wife reported that she had visited him two days before the facility notified her that he had facial bruising and a swollen lip, and the facility’s incident report categorized the injuries as a bruise of unknown origin. In the days leading up to the discovery of the injuries, staff and hospice documentation indicated that the resident had increasing agitation and combative behaviors during care, associated with his progressing dementia. A care plan meeting with the family and hospice nurse occurred shortly before the incident, during which staff discussed the resident’s overall decline, increased agitation, and strategies for staff approaches, including non-pharmacological interventions and medication changes. The care plan identified a problem of physical behaviors toward others, with interventions such as administering medications, attempting to refocus behaviors, and stopping care and re-approaching when the resident became agitated. The resident had a PRN haloperidol order entered shortly before the incident, but the medication administration record showed it had not been used. On the night shift prior to the discovery of the bruising, a CNA reported that the resident was very combative during incontinence and clothing changes, and that she completed care alone because the unit was short-staffed, despite the resident’s known behaviors. She described difficulty removing a soiled shirt while the resident’s arms were moving all over and stated she informed the nurse only that the resident was combative, without reporting any injury or bruising. Another CNA, who had put the resident to bed earlier without bruising present and later found him with a black eye and cut lip, stated she always used a second staff member when providing care to him and had advised the night CNA not to change him alone due to his behaviors. The night RN acknowledged being told the resident was combative but did not administer any medication to address behaviors. The facility’s dementia training policy emphasized the need for specialized, person-centered care and ongoing staff training, but staff interviews and the sequence of events showed that the resident’s known aggression and dementia-related behaviors were not consistently managed in a way that prevented injury, resulting in unexplained facial bruising and other bruises of unknown origin.
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