Inadequate Supervision of Dementia Resident Leads to Wandering Incident
Summary
The facility failed to implement individualized interventions for a resident diagnosed with dementia, resulting in an incident where the resident wandered into another resident's room and kissed them on the cheek. The resident, who had moderate cognitive impairment and was independent in using a wheelchair, was not adequately supervised despite having a care plan that included redirection and communication with family. The care plan lacked specific interventions for supervision, which contributed to the incident. Interviews with staff revealed that the resident was known to have episodes of confusion and was supposed to be closely monitored for wandering. However, the Charge Nurse and Director of Staff Development acknowledged that the resident was not adequately supervised, as evidenced by the incident occurring without staff intervention. The Director of Nursing noted that the resident's room was near the nursing station, yet no staff witnessed the resident leaving their room, indicating a lapse in supervision. The facility's policy required direct care staff to supervise residents with dementia, but this was not effectively implemented in this case.
Penalty
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A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with dementia and severe cognitive impairment, known to wander and exhibit physical behavioral symptoms, repeatedly entered other residents’ rooms uninvited, sometimes wearing only a brief and not leaving when asked. Other residents reported having to tell the resident to leave, physically push the resident out in a wheelchair, keep a bed in a high position to prevent the resident from getting in, and waking to the resident touching a foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged the resident’s frequent wandering and described redirecting, offering snacks and fluids, and brief one-on-one engagement, but the resident remained constantly on the go and did not stay at activities. Despite a care plan and a dementia protocol calling for identification of support needs and adjustment of interventions, the facility failed to provide effective supervision and behavioral management to prevent ongoing intrusive wandering into other residents’ rooms.
A resident with moderate cognitive impairment, dementia with behavioral disturbance, and a history of combative behavior during care did not have a care plan addressing dementia-related behaviors. During incontinence care, the resident became combative, grabbing and attempting to hit CNAs. One CNA placed a pillow over the resident’s arms and leaned on it to hold the arms down while continuing care, contrary to facility training and dementia care policy, which direct staff to use redirection, step away, and notify the nurse rather than using restraint-like measures. Another CNA was initially unsure whether to report the incident, delaying immediate notification to nursing staff.
A resident with dementia, agitation, and anxiety was admitted in a confused and combative state and quickly began wandering, entering other residents’ rooms, handling their belongings, and becoming physically aggressive with staff when redirected. His ordered psychotropic medication (including Risperidone) was not available on admission and was delayed until the second day, during which time he continued to roam hallways, refuse to stay in his room, and intrude into rooms of multiple residents, causing them discomfort and fear. Behavior notes and staff interviews described ongoing episodes of the resident striking staff, spitting on a nurse, lying on the floor at the nurse’s station, attempting to get into other residents’ beds, and being difficult to redirect. Residents reported feeling uncomfortable and scared when he entered their rooms, closed doors, lay on their beds, or spoke to them in a threatening manner. Despite persistent behaviors and complaints, continuous one-on-one supervision and effective monitoring were not implemented promptly, resulting in a failure to provide appropriate dementia care and services consistent with the facility’s own dementia care policy.
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 Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services, including non‑pharmacological interventions, for residents with dementia and behavioral disturbances, which resulted in resident‑to‑resident altercations and actual harm. Two residents with dementia and significant behavioral histories repeatedly wandered, entered other residents’ rooms, and displayed agitation and aggression without evidence of effective monitoring or individualized non‑pharmacological strategies to manage these behaviors or prevent altercations. The facility relied heavily on psychotropic medication adjustments and brief periods of increased supervision, without documenting or care‑planning specific behavioral interventions tailored to each resident’s needs. One resident had vascular dementia with behavioral disturbance, agitation, anxiety, sundowning, combative behavior at night, and a history of throwing a chair, walking naked, and visual hallucinations. Orders included multiple psychotropic medications such as Haldol, Ativan, Vistaril, Depakote, Trazodone, and later Klonopin, with several dose changes over time. Nursing notes repeatedly documented this resident wandering the halls, entering other residents’ rooms, pacing, yelling, slamming chairs and doors, being verbally and physically aggressive, and having explosive episodes. The care plan identified mood and behavior problems, including disruptive behavior, resisting care, socially inappropriate behavior, wandering into other rooms, exit seeking, and combativeness, but listed only general interventions such as consulting social services, administering medications, monitoring behaviors, and gentle redirection. There was no documented evidence of specific non‑pharmacological interventions being planned or implemented to address these behaviors. The second resident had diagnoses including behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, delirium, and later severely impaired cognition, with documented behaviors such as wandering daily, rejecting care, and physical and verbal behaviors toward others. This resident frequently wandered into other residents’ rooms and was found in their recliners or beds, yet the record showed no non‑pharmacological interventions to address wandering or to prevent altercations. Multiple incidents occurred between the two residents: one resident hit the other on the jaw while the victim sat near the nurse’s station; on another occasion, one resident repeatedly rammed a walker into the other’s legs, leading to mutual hitting and facial scratches; and later, the wandering resident entered the other’s room, resulting in a serious altercation where the victim was found on the floor with significant facial trauma, periorbital swelling, scalp laceration, and a large bruise from hip to knee. Despite these escalating events and the known mutual dislike between the two residents, interviews and record review confirmed that no new, individualized non‑pharmacological interventions were added beyond temporary increased or one‑on‑one supervision, and the facility did not effectively implement behavioral health services to prevent further resident‑to‑resident altercations. Title: Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations ShortSummary: Two residents with dementia and significant behavioral histories repeatedly wandered, entered other rooms, and displayed agitation and aggression without individualized non‑pharmacological interventions or effective behavioral health care plans. Staff documented frequent wandering, pacing, yelling, slamming furniture, and explosive episodes, and the care plans relied largely on psychotropic medications and general redirection rather than specific, person‑centered strategies. Multiple altercations occurred, including one resident striking another near the nurse’s station, an incident involving a walker being rammed into another resident’s legs with mutual hitting and facial scratches, and a later episode in which a wandering resident entered another’s room and sustained significant facial trauma, scalp laceration, and extensive bruising. Records and interviews confirmed that, despite these events and awareness that the two residents did not get along, the facility did not develop or implement comprehensive, individualized non‑pharmacological interventions to manage behaviors or prevent further resident‑to‑resident altercations.
Failure to Adequately Supervise and Manage Intrusive Wandering in a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, treatment, and services for a resident with dementia who exhibited intrusive wandering behaviors into other residents’ rooms. The resident had diagnoses of dementia, Alzheimer’s disease, hypertension, and unspecified protein-calorie malnutrition, with a Quarterly MDS documenting severe cognitive impairment, physical behavioral symptoms toward others, and frequent wandering. The resident’s care plan identified a potential for physical aggression related to dementia, triggers such as abrupt approaches, and interventions including redirection, distraction, offering snacks, and documenting behaviors and interventions. Despite this, the resident’s behavior log and care planning adjustments in response to ongoing intrusive wandering and room entries were not described, and the resident continued to enter other residents’ rooms uninvited and sometimes partially clothed. Multiple residents reported specific incidents of this resident entering their rooms and not leaving when asked. One resident reported that the wandering resident entered her room wearing only a diaper and had to be told to leave. Another resident stated that the wandering resident came into her room in a wheelchair, requiring her to get out of bed and physically push the resident out. A further resident reported keeping her bed in a high position so the wandering resident could not get into it, and another incident where she awoke to the resident touching her foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged that the resident wandered into other rooms and described efforts to redirect, offer snacks and fluids, and engage the resident in activities, but the resident did not consistently stay at activities and remained “on the go.” The facility’s dementia clinical protocol required the IDT to identify the resident’s level of support, review changing needs, and adjust interventions as needed, but the ongoing intrusive wandering and repeated room entries showed that the resident’s behaviors continued despite these general redirection efforts, leading to the cited deficiency in supervision and behavioral management.
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.
Failure to Adequately Monitor and Manage Dementia-Related Wandering and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and treat a resident’s dementia-related wandering and behavioral symptoms in accordance with its dementia care policy. Resident C was admitted with diagnoses including dementia with agitation and anxiety and was documented on admission as confused and combative. Within minutes of arrival, he refused to wait for a physical therapy evaluation, would not follow staff direction, moved into his roommate’s area, handled the roommate’s belongings, and made physical contact with the roommate. Verbal redirection was unsuccessful, and he became physical, striking staff. Later that evening, he and his roommate were screaming at each other, leading staff to temporarily move him to another room. During this period, he continued to leave his room, wander into other residents’ rooms, and remain physically combative with staff. The facility did not have Resident C’s discharge medications, including his scheduled Risperidone, available upon admission, and emergency medication obtained that night had little to no effect. His medications were not available until his second day at the facility. During this time, multiple female residents voiced that they wanted him kept away from them. Behavior notes documented that he was confused, ambulating in the hallways, refusing to stay in his bed despite repeated attempts, and wandering without purpose. He rummaged through his roommate’s belongings and irritated his roommate. Staff interviews confirmed that he repeatedly entered other residents’ rooms, was difficult to redirect, and was combative when staff attempted to intervene. One CNA reported that it was chaotic when he was not provided one-on-one supervision and that he wandered into other residents’ rooms, including climbing into bed with another resident as reported in shift report. Multiple residents described specific incidents of Resident C entering their rooms uninvited. One resident reported that he came into her room, shut the door, removed her wheelchair foot pedals from the bed, asked where to put them, and ultimately placed them in the trash before leaving. On another occasion, he lay on her bed until staff redirected him. Another resident stated that he entered her room, closed the door, sat on the empty bed, turned back the covers, made inappropriate hand signs, and told her to “shut up,” which left her feeling scared and uncomfortable. Behavior notes further documented that he continued to enter other residents’ rooms, strike staff during redirection attempts, spit on a nurse, lay on the floor at the nurse’s station, and exhibit exit-seeking behavior. Staff, including the Social Services Director and Administrator, acknowledged that he wandered everywhere, went into other residents’ rooms, and was aggressive with staff, and that he was not placed on one-on-one supervision until several days after admission, despite ongoing behaviors and resident complaints. These actions and inactions demonstrate the facility’s failure to provide appropriate monitoring and dementia care services to address his wandering and behavioral symptoms as required by its own dementia care policy. Additional documentation showed that Resident C wandered the facility for entire shifts, entered multiple residents’ rooms, upset residents, and at one point sat on another resident’s bed, removed his pants and socks, and attempted to lie down while the room’s occupant became angry and told him to leave. Staff required multiple attempts to redirect him from these rooms. Residents reported feeling uncomfortable and, in at least one case, scared by his presence and behavior in their rooms. The Social Services Director stated that the facility had believed he was not ambulatory and was surprised by his ability to walk everywhere upon admission, and also noted that he was more confused when off his original hospital medications. Despite the facility’s dementia care policy requiring assessment, individualized care planning, person-centered non-pharmacological approaches, environmental modifications, and ongoing monitoring of interventions for effectiveness, the record and interviews show that Resident C’s wandering and intrusive behaviors into other residents’ rooms persisted over several days without timely implementation of effective monitoring and supervision. The Administrator confirmed that Resident C wandered into other residents’ rooms and was aggressive with staff, and that other residents were upset because they were not used to residents entering their rooms. Staff accounts and behavior notes consistently described ongoing wandering, room entries, combative behavior, and difficulty with redirection over multiple days following admission. The delay in obtaining his scheduled psychotropic medications, the lack of immediate and sustained one-on-one supervision despite repeated incidents, and the continued reports from residents and staff about his intrusive and aggressive behaviors collectively demonstrate the facility’s failure to provide appropriate treatment and services for a resident with dementia-related wandering and behavioral symptoms, as required by its dementia care policy and regulatory standards.
Failure to Implement Abuse Risk Assessments and Non-Pharmacological Interventions for Dementia-Related Behaviors
Penalty
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.
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