Failure to Provide Person-Centered Dementia Care and Honor Resident Preference at Mealtimes
Penalty
Summary
Surveyors identified that a resident with dementia and anxiety, who was severely cognitively impaired and resided in a secure memory care unit, did not receive person-centered care consistent with her expressed preferences. Throughout the survey, the resident was observed to be pleasantly confused, non-verbal, and generally independent in her activities, which primarily involved self-propelling her wheelchair in the hallway outside her room and sitting away from the dining room table to watch others rather than engage. During a continuous observation over the lunch period, the resident repeatedly attempted to leave the dining room table and return to the hallway, clearly demonstrating a preference to be away from the gathered crowd. Despite these repeated attempts, CNAs physically returned the resident to the table multiple times and blocked her path when she tried to leave, including one CNA standing in her way and stating that the resident could not get past her. Another resident used the resident’s wheelchair armrest to jerk her back to the table and later placed hands over her arms to pull her back, while staff verbally thanked this peer for trying to keep her at the table. A different resident intervened to stop this pulling, expressing concern it could hurt the resident’s arm. The resident’s care plan lacked person-centered interventions addressing her preference to be away from the dining room table or individualized approaches for her anxious behaviors, and the record did not document staff efforts to prevent peers from redirecting her or to address resident-to-resident interactions related to these events.
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