Failure to Monitor and Intervene for Resident Wandering Led to Resident-to-Resident Sexual Incident
Penalty
Summary
The facility failed to provide adequate monitoring and implement care-planned interventions for a resident with a known history of wandering and severe cognitive impairment. This resident, who required maximum assistance for daily activities and was identified as wandering into other residents' rooms, was not consistently redirected or engaged in structured activities as outlined in the care plan. Prior to dinner, staff observed the resident wandering but did not increase monitoring or implement additional interventions until after an incident occurred. Later that evening, the resident was found partially undressed in another resident's room, where both individuals, each with severe memory deficits and dementia, were observed attempting to initiate sexual contact. The incident was interrupted by staff, and no physical injuries were noted. Documentation and staff interviews confirmed that the resident had a pattern of entering other rooms and that interventions to address this behavior were not fully implemented prior to the event.