Failure to Prevent Resident Intrusions Violates Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not preventing a resident with dementia from repeatedly entering other residents' rooms uninvited. Multiple residents, including those who were cognitively intact and those with varying levels of cognitive impairment, reported that this resident would enter their rooms, sit on their beds or in their wheelchairs, and in one case, sat on a resident's recently operated knee, causing pain and distress. Staff and residents confirmed that these intrusions were ongoing and that the affected residents did not want this behavior to continue. Observations and interviews revealed that staff were aware of the wandering behavior and its impact on other residents. Staff described redirecting the resident as the primary intervention, but acknowledged that these efforts were not always effective. Some staff reported that the resident could become combative when redirected and that interventions such as walking with the resident, offering activities, or using visual cues like STOP signs had limited or no success. Documentation showed that the resident continued to wander into rooms, including at night, and that staff sometimes had to take turns sitting with her to prevent further incidents. Despite being aware of the problem and receiving grievances from residents, the facility did not implement effective interventions to prevent the resident from entering others' rooms uninvited. The affected residents expressed discomfort, frustration, and, in one case, physical pain as a result of these intrusions. The facility's actions and inactions led to a failure to honor residents' rights to dignity, privacy, and self-determination as required by policy and regulation.