Failure to Prevent Resident Wandering and Inadequate Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement effective interventions and provide adequate supervision to prevent a resident with dementia and behavioral disturbances from wandering into other residents' rooms, invading their privacy, disturbing their environment, taking assistive devices, and making inappropriate comments. Despite documentation of the resident's history of physical aggression, resistance to care, and impulsivity, the care plan interventions such as 10- or 15-minute checks were inconsistently documented or not performed as required. The resident was observed to have frequent behaviors, including entering other residents' rooms without permission, and staff interviews confirmed that supervision was lacking, especially during night shifts. Multiple residents reported distressing encounters with the wandering resident, including incidents where assistive devices such as walkers were taken, resulting in falls and injuries. One resident, who was independent with ambulation using a walker and had multiple medical diagnoses including heart disease and osteoporosis, suffered two unwitnessed falls after her walker was moved out of reach by the wandering resident. These falls resulted in a laceration to the knee requiring sutures, a laceration to the hand, and a hematoma to the scalp. The affected resident expressed fear and distress due to repeated intrusions and threats from the wandering resident, and reported that her concerns were not believed by staff or her family. Other residents also reported frequent and distressing intrusions into their rooms, including being awakened at night, having personal belongings taken, and experiencing threats or attempted physical aggression. Staff interviews corroborated that the resident with dementia was not adequately supervised, particularly during evening and night shifts, and that interventions such as doorway sensors and increased checks were either not implemented or not consistently followed. Documentation gaps and lack of effective supervision contributed to ongoing incidents affecting the safety and well-being of multiple residents.