Failure to Supervise Memory Care Resident Leads to Inappropriate Contact
Penalty
Summary
Staff failed to provide adequate supervision for a resident with a history of alcohol dependence, alcohol-induced persisting dementia, stroke, aphasia, schizophrenia, and Wernicke's encephalopathy, who resided in a secure memory care unit due to elopement risk and aggressive behaviors. The resident, who was assessed as having intact cognition and required set-up assistance for daily activities, was allowed to leave a supervised smoke break early and return to the facility unsupervised after reporting feeling cold. Staff permitted the resident to wait alone in the activity room, and when the smoke break concluded, it was assumed the resident had returned to the unit without verification. As a result of this lapse in supervision, the resident entered another resident's room and was observed engaging in inappropriate physical contact with that resident, who requested the behavior stop but was ignored until staff intervened. Multiple staff interviews confirmed that the expectation was for memory care unit residents to be observed at all times when outside the unit, and the failure to do so directly led to the incident.