Failure to Prevent Resident Wandering and Room Entry
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and a history of wandering from entering another resident's room. The resident, who was identified as an elopement risk and had impaired safety awareness, was care planned for frequent monitoring and diversional interventions. Despite these interventions, the resident was able to wander into another resident's room during the night. The incident involved a resident with a history of traumatic brain injury and moderate cognitive impairment, who was approached in her room by the wandering resident. The resident who entered the room was wearing only a diaper brief and was observed touching the other resident's walker, causing the resident in bed to feel unsafe and emotionally distressed. The event was witnessed by staff, and the resident who felt threatened called 911, resulting in a police report being filed. Staff interviews confirmed that wandering into other residents' rooms was a known issue for certain residents, and staff described various redirection techniques. However, the incident demonstrated that the interventions in place were not sufficient to prevent the wandering resident from entering another resident's room and causing emotional distress. Facility documentation and staff statements indicated that monitoring and redirection were not consistently effective in preventing such incidents.