Failure to Prevent Resident-to-Resident Intrusions and Property Loss
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairment and wandering behaviors from repeatedly entering the rooms of other residents and taking or destroying their personal belongings. Multiple residents reported that this individual entered their rooms, removed or damaged their possessions, and in some cases, became physically aggressive when confronted. The affected residents expressed fear, frustration, and emotional distress as a result of these incidents, with some reporting physical altercations, including being struck or choked by the resident in question. Observations revealed that the facility attempted to use mesh-type barriers with stop sign notifications across doorways to prevent the resident from entering other rooms. Despite these measures, staff interviews indicated that it was nearly impossible to keep the resident from wandering into other rooms and taking items, as the resident was frequently in the hallways and staff could not consistently monitor or redirect her. Documentation in the electronic medical records showed numerous progress notes over several months detailing the resident's ongoing behaviors, including wandering, entering other residents' rooms, and taking or disturbing their belongings, often resulting in distress among other residents. The residents affected by these incidents were generally cognitively intact and valued the importance of maintaining their personal belongings, as documented in their Minimum Data Set (MDS) assessments. Staff, including CNAs and LPNs, acknowledged the ongoing issue and the negative impact on the residents' sense of safety and well-being. The Assistant Director of Nursing was unable to provide a clear answer regarding effective interventions to prevent these incidents, and the facility's actions were limited to placing barriers and attempting to monitor the resident, which proved insufficient.