Failure to Provide Adequate Supervision for Resident with Wandering Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a resident with known wandering and behavioral issues from entering another resident's room and attempting to take personal belongings during the night. The resident in question had a history of severe cognitive impairment, agitation, hallucinations, delusions, and physical behaviors that impacted her care and interactions. Despite documented behaviors such as wandering, aggression, and poor safety awareness, supervision was not consistently maintained, particularly during the overnight shift when a 1:1 sitter was not assigned. The resident's care plan and medical records indicated ongoing behavioral challenges, including restlessness, resistance to redirection, and attempts to enter other residents' rooms. Staff notes and psychiatric assessments repeatedly documented the resident's difficulty with redirection and her tendency to wander and interact inappropriately with others. On the night of the incident, staff responsible for supervising the resident were attending to other duties, leaving the resident unsupervised, which allowed her to enter another resident's room and take his cell phone and glasses. The incident was only discovered when the other resident called out for help. Interviews with staff confirmed that supervision was not maintained at all times, especially during the night shift, and that the resident was not assigned a dedicated 1:1 sitter during those hours. The lack of continuous supervision, despite the resident's documented behaviors and risks, directly led to the incident where she was able to access another resident's belongings and make physical contact, resulting in minor skin indentations. The facility's failure to ensure adequate supervision for a resident with known high-risk behaviors constituted the deficiency.