Failure to Update Care Plan After Repeated Wandering Incidents
Penalty
Summary
The facility failed to update and revise a resident's care plan with appropriate interventions following multiple incidents of wandering into other residents' rooms. Despite repeated episodes where a resident with significant cognitive impairment and a diagnosis of dementia was found in other residents' rooms and beds, the care plan remained unchanged after its initial creation. The only intervention documented was redirection, and there was no evidence of additional or modified strategies being implemented after each incident. Nursing notes and incident reports documented several occasions where the resident entered other residents' rooms, sometimes resulting in altercations or distress to other residents. In one instance, the resident was found asleep in another resident's bed, and in another, the resident became violent when redirected by staff, attempting to hit and bite them. The resident's behavior persisted over several months, with staff and family members being notified of the incidents, but no new interventions were added to the care plan to address the ongoing wandering and associated behaviors. Interviews with staff, including the DON, ADON, and CNAs, confirmed that the only intervention in place was redirection, and that the care plan had not been updated after each incident. The facility lacked a policy for revising care plans following such events, and the interdisciplinary team did not meet to develop new interventions after repeated episodes of wandering. This failure to update the care plan contributed to continued incidents affecting both the resident and others in the facility.