Failure to Implement Person-Centered Dementia Care and Monitor Wandering Behaviors
Penalty
Summary
The facility failed to ensure that a resident with severe dementia received appropriate person-centered care and interventions to maintain their highest practicable well-being. The resident, who was severely cognitively impaired and had a history of wandering, aggression, and behavioral disturbances, was repeatedly observed leaving their own room and entering other residents' rooms without staff awareness. On multiple occasions, the resident was found asleep in other residents' beds while the assigned staff were either unaware of their whereabouts or incorrectly assumed the resident was in their own room. Staff did not consistently monitor or engage the resident in meaningful activities to minimize wandering, despite care plan interventions that called for such engagement. Observations revealed that staff at the nurses' station and in the dining area were not attentive to the resident's movements, allowing the resident to wander unsupervised into other rooms. Staff only became aware of the resident's location after being prompted or when searching room by room. The care plan for the resident included interventions such as documenting wandering behavior, providing diversional activities, and encouraging participation in structured activities, but these were not effectively implemented. Staff interviews confirmed that the resident frequently wandered into other residents' rooms, sometimes becoming aggressive when redirected, and that staff were unable to prevent these behaviors. Documentation practices were also deficient, as staff primarily recorded aggressive behaviors but failed to document incidents of wandering, including entering other residents' rooms and sleeping in their beds. The social services director acknowledged that behavior tracking was not person-centered and that all behaviors, including wandering, should be documented. The director of nursing and other staff recognized that the lack of monitoring and documentation was unacceptable and that the resident's behaviors could lead to altercations with other residents.