Failure to Supervise Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with a history of wandering and dementia. The resident, who had diagnoses including a cervical fracture and unspecified dementia, was documented as wandering throughout the building and requiring continuous redirection to stay out of other residents' rooms. On one occasion, the resident was found in a storage area near the kitchen, which was not designated for residents, after being identified by a dietary aide. The resident stated they were looking for a cup of coffee and was subsequently redirected back to the nursing unit by a nurse aide. A review of the resident's clinical record revealed there was no care plan in place addressing the resident's wandering behavior. Staff interviews confirmed the resident's history of wandering and the incident where the resident accessed an unauthorized area. The Director of Nursing acknowledged that the resident had entered a non-resident area and that the situation was brought to the attention of nursing staff by dietary personnel. The lack of a care plan and insufficient supervision contributed to the resident's ability to access areas outside of their designated unit.