Failure to Implement and Document Dementia-Related Behavioral Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document individualized interventions and services for a resident with dementia and anxiety who was exhibiting escalating behavioral and emotional distress. The resident had documented diagnoses of unspecified dementia (moderate) with anxiety, anxiety, hypertension, and muscle weakness, and her care plan indicated moderately impaired cognition and dependence on staff for emotional, intellectual, physical, and social stimulation. Despite a dementia care policy requiring person-centered, non-pharmacological approaches and care plan interventions related to each resident’s symptomatology, the resident’s increased anxiety, crying, yelling, delusions, and preoccupation with her roommate were not consistently addressed with observable interventions or documented in the clinical record. On one observed day, the resident was initially sleeping when a CNA delivered her meal tray, after which she began loudly yelling statements such as “Stay out of my life” and “Get out of it.” The CNA left to notify an RN, and the resident continued to yell and appear agitated. The RN attempted redirection but the resident remained distressed; the RN reported that the resident had earlier accused staff of trying to kill her and believed she might have a urinary tract infection. Later that day, the resident was observed crying in bed, repeatedly calling out to her roommate not to leave her, while the roommate attempted to console her. Two CNAs entered to provide care and transfer assistance to the roommate but did not approach or intervene with the crying, anxious resident, who remained tearful and asking for a kiss when the surveyor left the room. On the following day, the resident was observed wandering, pacing, and appearing restless in her room. Multiple staff interviews confirmed that the resident frequently cries, hallucinates, worries, misses her family, and becomes very anxious and nervous, particularly in relation to her roommate, over whom she “hovers” and becomes preoccupied. Staff, including CNAs, an LPN, the DON, and Social Services, acknowledged that the resident has ongoing behavioral symptoms, including delusions and emotional lability, and that her behaviors had increased after a decrease in antidepressant medication at family request. Social Services documentation noted her anxiety and preoccupation with the roommate and with the roommate’s spouse. Despite these ongoing and escalating behaviors, the progress notes contained no documentation on the day of the observed increased behaviors regarding the episodes or any interventions implemented, and the existing care plan interventions remained general (e.g., consults, encouragement of activities, monitoring) without evidence of being actively implemented during the observed episodes of distress.
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