F0744

E

Failure to Individualize Dementia Care, Document Behaviors, and Supervise Residents With Repeated Resident-to-Resident Incidents

Zeeland, Michigan Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop individualized, person-centered interventions, to review and revise care plans, and to provide adequate supervision for multiple residents with dementia, resulting in repeated resident-to-resident incidents and undocumented behaviors. Several residents had diagnoses including Alzheimer’s disease, dementia with behavioral or psychotic disturbances, and anxiety or depressive disorders. For one resident with alcohol-induced dementia, Alzheimer’s disease, psychotic disorder with delusions, and major depressive disorder, CNA behavior documentation over a 30‑day period showed wandering, abusive language, threatening behavior, grabbing, pushing, yelling, screaming, and a sexually inappropriate episode. Despite this, there were no corresponding nursing progress notes or care plan changes addressing these behaviors, and staff were unclear why the resident was placed on 15‑minute checks or 1:1 supervision, with no explanation documented in the EMR.

The facility also failed to document and care plan multiple serious resident-to-resident incidents involving this same resident and others with dementia. One incident involved a resident with dementia and anxiety found in another resident’s bed, both with pants partially down, which was reported verbally by a CNA and known to the NHA, but not documented in the EMR, and no care plan updates were made for either resident. Another incident involved the same male resident entering a female resident’s room, climbing into her bed, calling her derogatory names, and having to be forcefully removed; staff statements describing this event were kept in a soft file outside the medical record, and no EMR documentation or care plan interventions were created. Staff reported being told by the NHA not to document this incident. In a separate event, the same resident barricaded himself in a room shared by two female residents by placing a chair against the door, requiring multiple staff and police assistance to gain entry; again, there was no EMR documentation of the incident.

Additional deficiencies in documentation and care planning occurred with other residents with dementia and behavioral symptoms. One resident with dementia and behavioral disturbances reported that the same male resident grabbed her by the neck and pushed her head against the wall; her guardian relayed this allegation to an RN, who could not find any incident report or EMR documentation, although another LPN acknowledged being informed and texting the NHA about it. Another resident with Alzheimer’s disease, dementia with psychotic disturbances, and generalized anxiety disorder had documented angry outbursts, refusal of medications, and conflicts with roommates, including striking another resident, but her care plan contained no person-centered revisions reflecting these behaviors or a scratching incident that had been initially documented as a resident-to-resident event and later reclassified by management as an injury of unknown origin. Overall, care plans for the residents reviewed, particularly the male resident with alcohol-induced dementia and multiple behavioral issues, lacked meaningful, person-centered interventions or revisions to address wandering, aggression, and resident-to-resident incidents, and key events were either omitted from the EMR or recorded only in non-medical risk management files.

The NHA acknowledged awareness of at least some of the incidents, including the sexual incident between two residents and the bed incident involving the male resident and a female resident, and admitted that staff did not document these events in the EMR or reflect physician and guardian notifications. The NHA also stated she was not fully informed of all incidents involving the male resident and another female resident and could not provide documentation of frequent monitoring after those events. Staff interviews revealed confusion about behavior documentation tasks, lack of awareness of documented behaviors, and reports that management directed them not to document certain resident-to-resident incidents as such. The care plan for the male resident with alcohol dependence and alcohol-induced persisting dementia listed wandering and exit-seeking but contained no meaningful, person-centered interventions or revisions to address his documented behaviors and repeated interactions with other residents.