Failure to Prevent Resident Room Intrusions and Protect Resident Rights
Penalty
Summary
Julia Ribaudo Extended Care Facility was found noncompliant with federal and state regulations regarding resident rights and the promotion of a dignified environment. Surveyors identified that the facility failed to ensure residents' personal spaces were protected from intrusions by other residents. Multiple residents reported ongoing issues with other residents, particularly those with severe cognitive impairments, wandering into their rooms uninvited, rummaging through personal belongings, and consuming their food. These incidents were documented through clinical record reviews, resident council meeting minutes, and direct resident interviews. Specific examples included one resident with severe cognitive impairment repeatedly entering the rooms of other residents, sitting on their beds, and taking their snacks. Residents affected by these intrusions expressed frustration, anger, and the need to hide their belongings or call for staff assistance to remove the wandering resident. The issue was persistent, as evidenced by repeated mentions in resident council meeting minutes over several months, with no clear documentation of resolution or effective intervention by the facility. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that resident wandering and room intrusions had been a recurring concern raised by residents. Despite some reports of improvement, the problem remained unresolved for several residents, as indicated by their continued complaints during group interviews and council meetings. The facility's failure to address these concerns and protect residents' rights to privacy and dignity led to the cited deficiency.
Plan Of Correction
Preparation, submission, and implementation of the Plan of Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our Plan of Correction is prepared and executed as a means to continuously improve the quality of care and to comply with state and federal regulatory requirements. The facility is unable to retroactively correct Resident 3 and Resident 29's personal space being impeded on by wandering residents 16 and 19. All residents who voiced concerns during the resident council meeting were offered interventions that will deter wandering residents from entering their rooms. To identify like residents that could be affected by wandering residents, the DON/designee will interview all current alert and oriented residents with BIMS of 12 and greater. To prevent reoccurrence, the NHA/designee will educate the IDT team completing concierge rounds to follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI. The team completing concierge rounds will follow up with the identified alert and oriented residents to monitor any further concerns or resolution. To prevent reoccurrence, nursing staff re-educated on the redirection of wandering residents to prevent the wandering of residents into peers' rooms. To monitor and maintain compliance, the DON/designee will interview 6 random alert and oriented residents with BIMS of 12 and greater to monitor resolution of wandering residents weekly x4 and then monthly x2. Results will be reviewed at QAPI.