Failure to Monitor and Supervise Resident with Wandering Behavior
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and moderate cognitive impairment, who was known to wander and required substantial assistance with activities of daily living, was not adequately monitored during the night shift. This resident entered another resident's room at approximately 4:00 a.m. and became trapped between beds and curtains while in a wheelchair. The incident was discovered after the roommate heard noises and alerted staff, who then found the wandering resident in the room. Documentation and interviews confirmed that the resident's wandering behavior was not monitored or recorded during the relevant shift, despite care plan interventions and facility policy requiring such monitoring for residents at risk of unsafe wandering. The resident whose room was entered had intact cognition and required supervision or assistance with daily activities. He reported the incident as a grievance, expressing concerns about privacy and safety. Staff interviews acknowledged awareness of the wandering behavior and the importance of supervision, especially at night when confusion can increase. Facility policies reviewed indicated that staff should identify and monitor residents at risk for unsafe wandering and provide supervision based on assessed needs, but these procedures were not followed in this case.