Failure to Prevent Resident with Dementia from Entering Other Residents' Rooms
Penalty
Summary
The facility failed to provide necessary services and supervision to a resident diagnosed with dementia who repeatedly entered other residents' rooms, resulting in a physical altercation and minor injuries to another resident. Despite being known to wander and having a history of confusion regarding his own room, the resident continued to access other residents' rooms even after being placed on 1-to-1 observation, then fifteen-minute checks, and eventually residing in a secured memory care unit. Staff interviews and nursing progress notes documented multiple incidents where the resident was redirected after entering other rooms, displaying aggressive behavior, and taking or mishandling other residents' personal items. The facility's policy required appropriate treatment and services for residents with dementia to ensure their highest practicable well-being. However, documentation showed that the resident continued to wander into other rooms and engage in disruptive and aggressive behaviors, including taking items and attempting to dispose of them inappropriately, despite interventions. The facility did not consistently ensure adequate supervision to prevent these incidents, placing both the resident and others at risk for further altercations.