Failure to Prevent Resident Wandering and Unwanted Room Entry
Penalty
Summary
The facility failed to prevent a resident with confusion and wandering behaviors from entering the rooms of other residents, resulting in multiple instances of unwanted intrusions. One resident, who has a history of PTSD, reported feeling uncomfortable and stated that the wandering resident would sometimes steal items from his room. Staff instructed this resident to secure his belongings to prevent theft. Observations confirmed that the wandering resident entered the rooms of four other residents, including while one was sleeping, and touched personal items such as shoes, chairs, and wheelchair leg rests. Staff interviews revealed that the resident was able to move freely throughout the facility, with staff relying on a wanderguard system for safety. Staff did not express concern about the resident entering rooms, except in the case of the resident with PTSD who had voiced discomfort. It was acknowledged by staff that the wandering resident had previously gone through another resident's closet and that there could be infection control concerns due to the frequent room entries. Facility policy requires interventions to reduce unwanted intrusions, but these were not implemented in this case.