Failure to Provide Ordered 1:1 Observation for Resident with Dementia
Summary
A resident with diagnoses of dementia, anxiety, and psychosis was admitted to the facility and exhibited severe cognitive impairment, as indicated by a BIMS score of 3. The resident displayed behavioral symptoms that interfered with activities, intruded on the privacy of others, and disrupted the living environment, including hypersexual behaviors and significant wandering. Due to these behaviors, a physician's order was in place for 1:1 observation every shift, and the care plan included this intervention to address the resident's needs. Despite the physician's order and care plan, the facility failed to provide 1:1 observation for the resident during the night shifts from 6:00 p.m. to 6:00 a.m. on multiple occasions. Staff interviews confirmed that the required 1:1 observation was not consistently implemented during these hours. This lapse in following the ordered intervention resulted in the resident not receiving the appropriate treatment and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Penalty
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Failure to provide person-centered dementia care interventions for a resident with dementia and Alzheimer’s disease. Staff documented constant wandering, exit seeking, entering other residents’ rooms, and episodes of physical aggression, but the care plan did not address the aggression and staff reported they did not know the resident’s triggers, likes, or effective redirection methods. The resident was repeatedly difficult to supervise, had altercations with other residents and staff, and was ultimately sent back to the hospital after unmanaged behaviors.
Failure to Supervise a Resident with Dementia and Wandering Behaviors: A resident with severe cognitive impairment, high wandering risk, and repeated falls did not have an individualized person-centered behavior plan for wandering or exit-seeking. Video showed the resident moving around the unit, attempting to follow visitors out an exit, entering another resident’s room, and remaining there undetected for about 44 minutes before being found crawling out with forehead bleeding. EMS transported the resident to the hospital, where the bleeding was documented as reinjury of prior sutured lacerations.
Failure to assess and evaluate wandering behaviors in a resident with dementia, hallucinations, and psychotic disorder. The resident was documented and observed entering other residents’ rooms, rummaging through belongings, and accusing another resident of stealing her dentures. Staff said they mainly used redirection and close observation, but there was no care plan or regular documentation addressing the wandering behavior, and the DON stated the behavior should have been assessed and included in the care plan.
A resident with dementia, severe cognitive impairment, wandering, and behavioral symptoms had a care plan with anxiety-related interventions, but staff did not consistently provide meaningful behavior management services. After a resident-to-resident altercation caused a superficial skin break, staff identified activity engagement when the resident entered others’ personal space, yet this intervention was not added to the care plan. Observations showed the resident wandering into rooms and approaching others without resident engagement activities in place, while staff mainly relied on separation, snacks, toileting, or redirection.
Missing Dementia Care Plan for A resident with dementia: The facility did not have a person-centered care plan addressing dementia care needs for a resident diagnosed with dementia, pleural effusion, and need for assistance with personal care. The resident was dependent for ADLs and mobility, had impaired understanding and decision-making capacity, and was observed lying in bed and speaking about unrelated topics. The ADON and DON confirmed no dementia care plan was in place, despite the facility’s policy requiring IDT care planning for residents with dementia.
Dementia care and supervision failure led to a resident-to-resident altercation after a resident with severe dementia was moved into and then out of a locked memory care unit without a documented reason. The resident had a history of aggression, routine dependence, and a need for personal space, while the other resident had severe cognitive impairment, intrusive wandering, and poor spatial awareness. The wandering resident attempted to enter the other resident’s room, both fell, and the wandering resident sustained a right intertrochanteric femur fracture requiring surgery.
Failure to Provide Person-Centered Dementia Care Interventions
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions for a resident with unspecified dementia and Alzheimer’s disease who displayed ongoing wandering, exit seeking, physical aggression toward others, and eventual rehospitalization. The resident’s care plan addressed impaired cognition and elopement risk with general approaches such as administering medications as ordered, avoiding too many choices, maintaining routine, calmly redirecting, and offering diversions, but it did not address the resident’s episodes of physical aggression toward others. Social services staff reported they did not really know the resident well, did not know his likes and dislikes, and had not yet added a useful redirection statement to the care plan. The resident wandered nearly constantly from admission, repeatedly triggered the exit alarm near his room, and was observed going in and out of other residents’ rooms. Staff reported they did not monitor him on admission to determine what triggered his wandering or other behaviors, and when asked about the causes of his restlessness, wandering, and aggression, social services stated it was just his dementia and they did not know. Staff also reported he had two episodes of physical aggression toward other residents and several toward staff before being discharged back to the hospital because his behaviors were not managed. One LPN reported that on one occasion the resident wandered all day, entered another resident’s doorway, became physically aggressive, and then urinated in the hallway immediately afterward; the LPN stated he could not verbalize his needs and may have been stressed because he needed to urinate and did not know where his bathroom was. Additional staff interviews described the resident as constantly wandering, entering other residents’ rooms, attempting to remove his pants, and being difficult to supervise. A CNA reported trying to engage him in activities to reduce wandering without success, while another LPN reported the resident would benefit from more one-to-one staffing. Family reported the resident had previously been admitted to a behavioral health hospital for physical aggression and had been open with the facility about his need for dementia care interventions and close supervision. The resident had also been evaluated for behavioral health services by the facility’s contractual provider, and staff noted that interventions such as familiar items from home and individualized redirection had not been incorporated into his care plan. The record also showed staff education gaps related to dementia care training, including person-centered care plans and dementia-related behaviors.
Failure to Supervise and Individualize Dementia Behavior Care
Penalty
Summary
The facility failed to provide individualized behavioral interventions and sufficient supervision for a resident with dementia, severe cognitive impairment, wandering, and exit-seeking behaviors. The resident was admitted with diagnoses including dementia, bipolar disorder, macular degeneration, repeated falls, and a displaced comminuted fracture of the left tibia. The admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and the wandering risk assessment identified the resident as high risk for wandering. The resident’s record also documented impaired thought processes and wandering behaviors occurring 4 to 6 days weekly. The resident’s care plan addressed mood-related concerns and psychoactive medication use, but it did not include an individualized person-centered plan to address the resident’s dementia-related wandering, elopement risk factors, or known history of wandering. The record also showed multiple falls after admission, including falls on several dates before the incident in question, and the resident was transferred to an ED after sustaining forehead lacerations and bruising from a prior fall. A psychiatric note described worsening confusion, anxiety, restlessness, agitation in the evenings and at night, and severe cognitive impairment, with the resident oriented to person only. On the day of the incident, video surveillance showed the resident wandering the unit in a wheelchair, approaching the nurse’s station without staff noticing until close proximity, attempting to follow visitors out an exit door, testing doors, and entering another resident’s room. The resident remained in that room for approximately 44 minutes without staff awareness or redirection and was later found crawling out of the room with blood on the forehead. Staff responded after the resident was discovered, and EMS transported the resident to the hospital. Hospital records documented that the forehead bleeding was due to reinjury of previously sutured laceration sites from an earlier fall. The facility later confirmed that it had not developed or implemented a person-centered dementia care plan with specific interventions for the resident’s wandering, exit-seeking, combative behaviors, or frequent falls, and had not adequately supervised or redirected the resident during the incident.
Failure to Assess and Care Plan Wandering Behaviors in a Resident With Dementia
Penalty
Summary
The facility failed to assess and evaluate wandering behaviors for a resident with dementia and other psychiatric diagnoses, including entering other residents’ rooms and going through personal belongings. The resident’s significant change MDS identified severe cognitive impairment and worsening behaviors, and the behavioral symptoms CAA identified worsening behaviors with hallucinations, isolation, pain, anxiety, hollering out, and disruptive sounds; however, it did not comprehensively assess wandering or include a plan to minimize it. The resident was documented as wandering into three other residents’ rooms and being caught digging in drawers, and later was observed wandering down a hallway and entering another resident’s room. One cognitively intact resident reported that the resident repeatedly entered his room, accused him of stealing her belongings and dentures, rummaged through his closet, and became upset when told to leave. Staff interviews confirmed the resident wandered into other residents’ rooms, often after meals and possibly more frequently in the evening or night, but staff described the response as redirection and close observation. Multiple staff members stated there was no care plan or regular documentation addressing the wandering behavior, and the DON stated the resident’s wandering should have been assessed and the care plan updated to identify the behavior and interventions.
Failure to Implement Behavior Interventions for a Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with dementia and behavioral symptoms. The resident’s MDS documented long- and short-term memory problems, severe cognitive deficits, rejection of care, wandering, and physical and verbal behaviors, along with diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, depression, and psychotic disorder. The care plan identified behaviors including constant worry, repeated voicing of concerns, crying, restlessness, pacing, attention seeking, verbal statements of nervousness, looking for parents, and fear, with interventions such as reassurance, redirection, 1:1 bedside activities, and environmental changes during anxiety. The facility investigation report showed the resident had an altercation with another resident after invading that resident’s personal space, and the other resident made physical contact that caused a superficial break in the skin. After the incident, staff separated the residents and identified that staff would engage the resident in an activity when the resident began consistently entering other residents’ personal spaces. However, there was no evidence that this intervention was added to the resident’s care plan, and staff later confirmed that no new intervention had been implemented for the resident-to-resident incident. Survey observations showed the resident wandering, entering other residents’ rooms, approaching residents in the sitting area, and spending time without any documented resident engagement activity in place. Staff were observed moving the resident back to the recliner or redirecting the resident, but no independent activities were offered during several observations. Interviews with nursing assistants, medication aides, social services, and the DON showed the unit staff generally relied on separating residents, offering snacks, toileting, or calming the setting, and stated that unit staff did not provide activities, while activity staff only did 1:1 activities a few times per week.
Missing Dementia Care Plan for Resident With Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed dementia care needs for one resident with a diagnosis of dementia. The resident was originally admitted on 11/29/2023 and re-admitted on 4/16/2026 with diagnoses including dementia, pleural effusion, and need for assistance with personal care. The MDS dated 4/19/2025 indicated the resident sometimes understood others, was dependent for ADLs, and was dependent for all mobility. The H&P dated 3/15/2026 stated the resident did not have the capacity to understand and make decisions. During observation on 5/18/2026, the resident was lying in bed and did not directly respond to questions, instead speaking about unrelated topics. During review of the resident’s care plans with the ADON on 5/20/2026, no care plan for dementia was found. The ADON stated the resident had a diagnosis of dementia and should have a care plan with dementia interventions tailored to the resident’s needs. The DON stated there should be a specific care plan for dementia created for the resident, with interventions addressing cognitive needs, and that the absence of such a care plan can result in delays in care and unmet resident needs. The facility policy on Dementia Care stated residents with dementia are to receive appropriate treatment and services through an interdisciplinary care planning process.
Dementia Care and Supervision Failure Leading to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide effective person-centered dementia care for a resident with severe dementia, behavior disturbances, anxiety disorder, and psychotic disorder with delusions, and the resident was moved into a locked memory care unit and then moved back to the skilled unit without a documented reason. The resident had longstanding care plan interventions related to aggression, agitation with routine changes, and a preference for personal space and being left alone, and staff interviews showed he did not do well with change. Although staff discussed the room change in an IDT morning meeting and one staff member disagreed with the move because of the resident’s need for routine and private space, the resident was moved to the memory care unit anyway. Staff later stated the move was intended to get him out of his room and address increased isolation, but the record did not show a documented reason for the transfer. After the room change, the resident became involved in a resident-to-resident altercation. A behavior event documented that he pushed a wandering resident who attempted to enter his room, and the psychosocial stressor identified was the resident’s new admission to the memory care unit. An IDT note stated the wandering resident walked by the room and attempted to enter it, and the resident pushed him away to redirect him from his room. Staff interviews indicated the resident had been demonstrating increased aggression after returning from the memory care unit, and the resident’s son was told the room change was due to decreased activity and a desire to get him out of his room more often. The other resident involved had dementia and Alzheimer’s disease, severe cognitive impairment, intrusive wandering, poor spatial awareness, and a history of pacing and entering others’ personal space. His care plans addressed wandering, restlessness, and behavioral symptoms, but the fall care plan did not include an approach for safety monitoring or supervision before the incident. On the day of the event, he attempted to enter the other resident’s room without invitation, staff observed the interaction, both residents lost their balance and fell, and the wandering resident complained of right hip and leg pain, could not bear weight, and was sent to the hospital. He was diagnosed with a right intertrochanteric femur fracture and underwent surgical repair. Later interviews indicated the facility investigation determined the fall was unwitnessed, and the Executive Director stated both residents were not provided appropriate supervision or monitoring to prevent the incident.
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