F0744

E

Failure to Implement Abuse Risk Assessments and Non-Pharmacological Interventions for Dementia-Related Behaviors

Shelbyville, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatments, services, non-pharmacological interventions, and abuse risk assessments for residents with dementia and severe cognitive impairment, particularly in relation to resident-to-resident and resident-to-staff incidents. Several residents were identified as having dementia or Alzheimer’s disease with behavioral disturbances, and Minimum Data Set (MDS) assessments documented severe or moderate cognitive impairment. Despite this, the medical records for some residents, including those involved in incidents, did not contain abuse risk assessments to determine whether they were at risk of being victims or perpetrators of abuse.

One resident with dementia and severe cognitive impairment was involved in an incident where another cognitively impaired resident put a hand on her face; a CNA witness described the action as the second resident appearing to get mad and smacking the first resident, with apparent contact to the cheek under the eye. Neither resident’s record contained a documented risk assessment for abuse risk as victim or perpetrator. Another resident with Alzheimer’s disease and dementia with behavioral disturbance exhibited a pattern of sexually inappropriate and intrusive behaviors over an extended period, including grabbing the buttocks, breasts, and attempting to kiss CNAs, exposing genitals in public areas, walking naked in hallways, urinating and defecating outside the bathroom, following female residents to their rooms, entering or attempting to enter female residents’ rooms, and attempting or making physical contact with female residents while they were seated or asleep. Nursing progress notes repeatedly documented these behaviors and, in many instances, either documented no intervention or only minimal verbal redirection, reminders that the behavior was inappropriate, or simple monitoring.

The same resident’s care plan identified behavioral problems directed at others and an inability to differentiate socially appropriate from inappropriate behaviors, and it listed multiple non-pharmacological interventions such as specific redirection strategies, engagement in activities of interest, and one-to-one supervision. However, there was no documented evidence that staff implemented these listed non-pharmacological interventions beyond repeated verbal redirection, monitoring, and occasional direction to watch a movie or have a snack. Another severely cognitively impaired resident was documented as the alleged victim of breast touching by the behaviorally disturbed resident, and was observed during the survey sitting in the dementia unit day room covered with a blanket, unlike other residents. Multiple staff, including CNAs, RNs, LPNs, and care plan staff, reported either not witnessing the inappropriate behaviors firsthand or only having hearsay knowledge, and facility leadership and care planning staff confirmed that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that the electronic record system did not provide an actual abuse risk assessment. The facility’s own Abuse Prevention policy called for special attention to identifying behaviors that increase a resident’s potential for abusing others or being a victim, and for including appropriate interventions on care plans and communicating them to direct care staff, but the documentation showed that these expectations were not met for the residents involved.

Throughout the documented period, the resident with Alzheimer’s disease and behavioral disturbance continued to display sexually inappropriate and intrusive behaviors toward staff and female residents, including repeated touching or attempts to touch staff and residents, making sexual comments, and exposing himself in public areas. Progress notes showed that staff responses were often limited to telling the resident the behavior was inappropriate, redirecting him, assisting with clothing or hygiene after episodes of disrobing or incontinence, or simply monitoring him, with no consistent documentation of the broader, individualized non-pharmacological interventions outlined in the care plan. Additionally, the facility did not document completion of the ordered referral to a geriatric psychiatric hospital for this resident. Social services and care plan staff acknowledged that they were not aware of specific abuse or neglect risk assessment tools being used, and that the existing social history assessment was not designed to evaluate resident-to-resident or staff-to-resident abuse risk, despite the facility’s written policy requiring identification of such risks and inclusion of appropriate interventions on care plans.