F0745

D

Failure to Provide Social Services and Repeat BIMS After Cognitive Decline and Wandering

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide medically-related social services and to repeat a Brief Interview for Mental Status (BIMS) after a documented change in cognition for one resident with dementia and substance use disorders. The resident had vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, and chronic pain. A prior wander risk evaluation identified the resident as low risk for wandering, and a quarterly MDS assessment documented moderately impaired cognition with a BIMS score of 12, independence in mobility, and no wandering behaviors. The resident’s care plan identified impaired cognitive function/dementia, poor impulse control, a history of altercations, psychoactive drug use, fall risk, alcohol abuse, and risk for disorientation and confusion, with interventions including monitoring and documenting changes in cognitive function and behavior, reorientation, supervision, and every 15‑minute monitoring.

Beginning in late January, multiple nursing notes documented a clear change in the resident’s cognition and behavior, including confusion, exit seeking, wandering into other residents’ rooms, and repeated attempts to reach the elevator and leave the facility. On one date, a nurse documented that the resident expressed a desire to leave and was placed on every 15‑minute checks. Subsequent notes over several weeks by various LPNs described increased confusion, wandering, searching for family members, and persistent exit‑seeking behaviors, including continuously checking the elevator. Psychiatric evaluations and APRN notes during this period identified functional and cognitive decline, increased confusion and agitation, exit‑seeking behavior, sundowning, and evidence of cognitive decline, and documented that the resident remained on every 15‑minute checks for exit‑seeking behavior.

Despite these documented changes in cognition and behavior from late January through late February, review of the clinical record showed no evidence that social services met with or assessed the resident following the initial noted change in cognition. The record also lacked documentation of a repeat BIMS assessment from the time of the change through early March. The Director of Social Services acknowledged awareness of the resident’s cognitive decline, increased confusion, and wandering since January but confirmed he did not meet with the resident or reassess the BIMS as required with a change in cognition. The DON stated that social services should have evaluated the resident upon determination of a change in behavior and/or cognition and that a repeat BIMS should be completed with any change in cognition. The facility’s Dementia Care policy directed that appropriate treatment and services be provided to residents with dementia, that care plans be monitored and revised as necessary, and that appropriate referrals be made if current interventions were ineffective or if there was a decline in psychosocial, mood, or behavioral status.