A facility failed to conduct abuse risk assessments and to implement care-planned non-pharmacological interventions for several cognitively impaired residents with dementia and behavioral disturbances. One resident with severe cognitive impairment was struck on the face by another cognitively impaired resident, yet neither had documented abuse risk assessments. Another resident with Alzheimer’s disease and behavioral disturbance repeatedly engaged in sexually inappropriate and intrusive behaviors toward staff and female residents, including grabbing buttocks and breasts, exposing genitals, entering or attempting to enter female residents’ rooms, and touching or attempting to touch female residents while seated or asleep. Documentation showed that staff responses were often limited to verbal redirection, reminders that behavior was inappropriate, monitoring, and basic assistance with clothing or hygiene, with no consistent evidence that the broader, individualized non-pharmacological interventions listed in the care plan were implemented. A severely cognitively impaired resident was also identified as an alleged victim of breast touching by this behaviorally disturbed resident. Facility staff and leadership acknowledged that the social history assessment in use was for trauma-informed care and not an abuse risk assessment, and that no specific abuse risk assessment tool was used, despite an abuse prevention policy requiring identification of residents at risk of abusing others or being victims and inclusion of appropriate interventions on care plans.
Failure to update a dementia care plan for a resident with Alzheimer's dementia, DM2, repeated falls, and major depression. The resident became increasingly agitated, shouted profanities, isolated, refused care, and was heard cursing in his room; staff stated his dementia-related behaviors were escalating and had increased after he did not receive the correct dose of Seroquel. The ADON and Activity Director also reported he had stopped attending activities and had knocked his tray off the table, yet no updated dementia care plan was in place to address the behaviors.
A cognitively impaired, wandering resident with dementia and a history of entering other residents’ beds was care planned with diversional and structured activity interventions but was left unsupervised long enough to leave the common area and enter a male resident’s room. An activity aide assigned to remain in the common area did not engage the resident in 1:1 activities and could not state when the resident left or whether she herself had left the area. Staff later found the fully dressed female resident lying in bed with an unclothed male resident, with both appearing calm and showing no signs of injury, while the male resident later reported that the woman had come into his room, sat on his bed, and would not leave despite his requests.
A resident with severe dementia, multiple comorbidities, and a history of combative behavior during care was found with a black eye, swollen lip, and additional bruising of unknown origin after staff provided incontinence and clothing care while short-staffed and without assistance. Despite a recent care plan meeting noting increased agitation, identified behavioral interventions, and a PRN haloperidol order, staff did not administer the PRN medication, did not consistently follow the care plan to stop and re-approach when the resident became agitated, and did not ensure two-person assistance during care as practiced by other CNAs. The resident’s injuries were discovered after the shift in which a CNA reported significant combativeness but no observed bruising, and the facility was unable to determine how the injuries occurred, demonstrating a failure to provide appropriate dementia-focused care and supervision to prevent injury.
The facility did not update care plans or implement new interventions after a resident with dementia exhibited aggressive behaviors, including physically striking other residents in the dining room. Staff were not consistently aware of or following seating arrangements meant to prevent further incidents, and there was no documentation of psychiatric evaluation after the altercations.
Two residents with dementia and known wandering behaviors were not adequately supervised, resulting in one resident entering another's room and lying in her bed for over 30 minutes without staff intervention. Staff failed to immediately redirect or remove the resident, despite both having care plans requiring such actions, and facility policies mandating supervision and prompt intervention for wandering behaviors.
A resident with severe dementia and a history of being combative during care was injured when a CNA, working alone, attempted to reposition her during peri care. Despite care plan instructions to provide care in pairs when the resident was overly stimulated, the CNA proceeded alone, and the resident sustained a left humerus fracture during the episode. Staff interviews confirmed that care should have been paused and assistance sought when the resident became combative.
A resident with moderate dementia and anxiety exhibited escalating behaviors including yelling, crying, delusions, pacing, and intense preoccupation with a roommate, yet staff did not consistently intervene or document specific behavioral interventions during observed episodes. On one day, the resident loudly yelled and became agitated after a CNA delivered a meal tray; an RN attempted redirection but the resident remained distressed, and later that day two CNAs provided care to the roommate while the resident continued crying and calling out without staff engagement. Staff interviews and social services notes confirmed ongoing anxiety, hallucinations, and obsessive focus on the roommate, with acknowledged increases in behaviors after an antidepressant dose reduction, but progress notes lacked documentation of the observed behavioral incidents or targeted interventions, contrary to the facility’s dementia care policy requiring person-centered, non-pharmacological approaches and individualized care plan implementation.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
A resident with mild dementia and high elopement risk repeatedly attempted to leave the facility, triggering alarms and requiring staff intervention. Staff responses were limited and not always documented, and some staff lacked required dementia training and were unfamiliar with elopement prevention procedures, resulting in inadequate care and monitoring.
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