Failure to Revise Care Plan for Resident's Wandering Behaviors
Penalty
Summary
The facility failed to revise the care plan for a resident who exhibited wandering behaviors, specifically entering other residents' rooms and interacting with their belongings. Multiple interviews with staff and another resident confirmed that the resident frequently wandered into others' rooms, particularly during the evening and night. Staff reported redirecting the resident and providing items to fidget with or engaging her in activities as interventions. Progress notes documented ongoing wandering behaviors, increased behavioral symptoms, and difficulty redirecting the resident, sometimes resulting in agitation. Despite these documented behaviors and staff interventions, a review of the resident's care plan revealed that it only addressed elopement risk related to cognitive loss/dementia and did not include any interventions specific to wandering into other residents' rooms. The Director of Social Services confirmed that the care plan lacked appropriate interventions for this behavior. The facility's policy required individualized, person-centered, non-pharmacologic interventions for behavioral symptoms to be implemented and the care plan updated accordingly, which was not done in this case.