Failure to Monitor, Document, and Address Dementia-Related Behaviors and Environmental Safety
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for residents with dementia, specifically related to behavior monitoring, care planning, documentation, environmental safety, and staff response. One resident with dementia, mood disturbance, and major depressive disorder with psychotic symptoms had a history of severe cognitive impairment and behavioral symptoms, including aggression toward staff and other residents. Documented incidents included lunging and swinging at staff, verbal aggression, and attempts to grab another resident. Additional facility-reported incidents described the resident making contact with another resident’s neck in a common area and entering another resident’s room and grabbing her forearm, as well as an episode where the resident was found in another resident’s room with both hands firmly gripping her wrist while yelling delusional statements. Despite these events, there was no nursing documentation in the record for at least one of the reported incidents, and the care plan, which addressed behavioral symptoms related to dementia, was not revised with new or updated interventions following the new or escalating behaviors. The same resident was also found eating a denture cleaning tablet (Polydent) after it had been left in his room on the dementia unit. Staff interviews confirmed that denture tablets and other personal hygiene items should not be left in resident rooms on a dementia unit and should instead be stored away from resident access. The incident required consultation with poison control and monitoring for adverse symptoms, but the underlying issue was that the denture tablet had been left unsecured in the room of a cognitively impaired resident. The facility’s own behavior management policy required investigation of behaviors to determine root cause and daily monitoring and documentation of target behaviors, but the record lacked documentation of at least one behavior incident and did not show that the care plan had been updated in response to the resident’s new or increased behaviors. A second resident with Alzheimer’s disease, anxiety, unspecified psychosis, impaired cognition, and decreased visual acuity was observed sitting on the floor in a common area in front of the nurse’s station while two CNAs were nearby and did not assist her until the facility administrator intervened and helped her to a couch. Staff later reported that this resident sometimes sits herself on the floor. The resident’s care plan addressed altered communication, risk for injury and/or social isolation due to decreased visual acuity, impaired cognition, and behavioral symptoms, with interventions such as assessing and modifying the environment for safety, cueing, reorienting, supervising as needed, and intervening when inappropriate behavior is observed. However, there was no specific care plan addressing the resident’s behavior of sitting on the floor, and there was no nursing documentation, observation, or assessment in the progress notes regarding this floor-sitting episode, despite staff acknowledging that a resident found on the floor should be assessed and documented and that staff should consider the reasons for such behavior.
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