Failure to Provide Competent Dementia Care and Appropriate Response to Combative Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were competent to provide appropriate care and services to a resident with dementia-related behaviors. The resident was admitted for short-term rehabilitation with diagnoses including Parkinsonism, anxiety disorder, and unspecified dementia with behavioral disturbance, and had a Minimum Data Set indicating moderate cognitive impairment. Review of the resident’s care plan showed no plan of care addressing behaviors related to dementia. A nursing progress note documented that the resident was combative with care and had smeared bowel movement on himself and the bed. During a night shift, a CNA (Staff H) attempted to provide incontinence care to the resident, who was covered in feces. The resident had previously grabbed Staff H’s wrist during care, so she requested assistance from another CNA (Staff G). While assisting, the resident grabbed Staff G’s hands and bent her fingers and then attempted to hit Staff H when they rolled him. In response, Staff H placed a pillow over the resident’s arms, leaned her right arm on the pillow to hold his arms down, and told him he was not going to be combative while she continued to clean him with her left hand. Staff H reported holding the resident in this manner for about 30 seconds until they were able to dress him and transfer him to a chair. Staff G reported being unsure about what she had witnessed and initially did not think she needed to report the event immediately, intending instead to ask the DON the next morning. Another CNA (Staff I) advised that the incident needed to be reported to a nurse, and the other CNA reported it. The nurse manager (Staff B) was notified and learned that Staff H had used a pillow to lean on the resident to prevent him from striking staff, which was not consistent with the facility’s training that CNAs should notify the nurse, step away, and reattempt care if redirection is unsuccessful when a resident is combative. Review of the facility’s dementia care policy indicated that restraints should not be used unless safety is an issue and only according to policy, with staff instructed to check with a supervisor before using restraints. The lack of a behavior-focused care plan and the use of a pillow to physically restrict the resident’s movement during care formed the basis of the deficiency.
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