Failure to Monitor and Intervene for Dementia Residents with Wandering Behaviors
Penalty
Summary
The facility failed to adequately monitor and intervene for two residents with dementia who exhibited wandering behaviors. On the morning of 12/8/25, one resident with severe cognitive impairment was observed entering another cognitively impaired resident's room and lying in her bed, both fully clothed. Video surveillance reviewed by the administrator showed the resident wandering unsupervised throughout the facility for about an hour before entering the other resident's room. Staff did not remove the resident from the room until over 30 minutes after entry, and there was no staff presence observed during this period. Both residents had documented histories of wandering and confusion, with care plans indicating the need for staff to distract and intervene as appropriate. Interviews with staff revealed that when the incident was discovered, immediate intervention did not occur. A CNA who found the resident in the bed reported the situation to an RN, who was occupied with medication administration and did not act immediately, instead waiting for the day shift to assist. The RN stated uncertainty about the nature of the relationship between the residents and did not know how long the resident had been in the room. Facility policies required immediate redirection and supervision of wandering residents, but these were not followed, resulting in a lack of timely intervention for both residents involved.