Failure to Implement Effective Interventions for Resident with Dementia-Related Wandering
Penalty
Summary
The facility failed to develop and implement adequate person-centered interventions for a resident diagnosed with dementia who exhibited wandering behaviors, including entering other residents' rooms. The resident, who had a BIMS score of 5 indicating poor cognition and a diagnosis of non-Alzheimer's dementia, was observed and reported by staff and other residents to frequently wander the hallways, enter other residents' rooms, turn off lights, and take items belonging to others. The care plan for this resident included monitoring and redirection, but these interventions were not effective in preventing the resident from continuing these behaviors. Multiple incidents were documented where the resident was found in other residents' rooms, sometimes becoming verbally aggressive when asked to leave. Staff interviews confirmed that the resident became agitated when redirected and continued to wander despite interventions. Other residents reported discomfort and distress due to the resident's actions, including invasion of privacy and taking personal items. The resident's behaviors were also noted to have led to falls, including one incident where the resident sustained a bump on the forehead and was diagnosed with a closed fracture of the temporal bone after being found on the floor in the hallway. The facility's records and staff interviews indicated ongoing challenges in managing the resident's wandering and associated behaviors. Despite recognition of the need for more intensive interventions, such as one-on-one monitoring or memory care placement, the existing care plan and implemented strategies were insufficient to prevent the resident from wandering into other residents' rooms and causing distress or injury.