Failure to Provide Adequate Supervision for Residents with Wandering Behaviors
Penalty
Summary
The facility failed to provide adequate supervision for two residents with known wandering behaviors, resulting in a resident-to-resident interaction. Both residents had diagnoses of dementia and severe cognitive impairment, with one also diagnosed with bipolar disorder and schizoaffective disorder. Care plans for both residents identified risks related to wandering and directed staff to redirect and encourage recreational activities as diversions. Despite these interventions, one resident was found in another resident's room, sitting on the lap of the other resident with their undergarment around their ankles, while the other resident attempted to push them away. Staff had last observed the residents separately less than half an hour before the incident, but were unaware of their whereabouts at the time of the event. Facility documentation and interviews confirmed that both residents had a history of wandering, and the incident occurred in a room equipped with a video camera. The facility's policy required staff to monitor for behaviors that could provoke reactions, including sexually aggressive behavior, and to take steps to protect residents from abuse. However, the report did not identify how the residents were able to access another resident's room without staff knowledge, indicating a lapse in supervision and monitoring as required by the residents' care plans and facility policy.