Failure to Address Resident Wandering in Comprehensive Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan addressing a resident's behavior of wandering into other residents' rooms, despite this behavior being identified on both the admission and significant change MDS assessments. The resident, who was admitted with Alzheimer's disease and mood disturbance, exhibited repeated incidents of wandering, agitation, and aggression, as documented in multiple nursing progress notes. These behaviors included entering other residents' rooms, becoming agitated when redirected, and displaying physical and verbal aggression toward staff. Although the MDS assessments triggered behavioral symptoms and indicated that these should be included in the comprehensive care plan, the care plans dated after admission did not specifically address the wandering behavior. The care plan included interventions for emotional, intellectual, and social needs, as well as for potential aggression, but omitted targeted interventions for wandering into other residents' rooms. This omission persisted even after ongoing documentation of the resident's wandering and related behaviors in the clinical record. Interviews with facility staff, including LPNs and nursing supervisors, confirmed that the behavior of wandering into other residents' rooms should have been included in the care plan. The facility's policy required that the care plan be kept current and updated by all disciplines when new problems arise. Despite this, the care plan was not updated to address the resident's wandering behavior until several months after admission, following repeated incidents and staff acknowledgment of the oversight.