Failure to Prevent Wandering Resident From Entering Another Resident’s Room and Bed
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent a known confused, wandering resident from entering another resident’s room and bed. The female resident had Alzheimer’s disease, dementia, severe cognitive impairment per BIMS, a history of wandering, and was assessed as high risk for abuse/neglect and for wandering/elopement. Her care plan identified her as an elopement risk/wanderer related to impaired safety awareness, dementia, and Alzheimer’s disease, and included interventions such as providing pleasant diversions, structured activities, walking inside, toileting, and reorientation strategies. Despite these identified risks and planned interventions, she was able to leave the common area unsupervised and enter a male resident’s room. On the evening of the incident, staff documentation and interviews show that the female resident was last seen in the 200-unit common area near the nurse’s station after dinner, seated on a couch around 6:30 p.m., with an activity aide assigned to remain in the common area and keep residents engaged. The activity aide reported that she did not engage the resident in 1:1 activities and later heard commotion down the hall around 7:00–7:30 p.m., at which time she noticed the resident was no longer in the common area. The aide did not know when the resident had left or whether she herself had left the common area. Another CNA stated that the female resident wanders often, goes into other residents’ beds as a typical behavior, and is usually redirected when seen, but on this occasion staff were likely busy and no one saw her walking down the hall. During this period of inadequate supervision and failure to effectively implement the resident’s care-planned interventions, the female resident entered a male resident’s room. The final incident report documented that staff entered the room and observed the fully dressed female resident lying in bed with the male resident, who was unclothed. Both residents’ hands were at their sides or resting on the bed, no movement or sexual activity was observed, and both appeared calm with no signs of distress. Post-incident assessments found no injuries or signs of trauma, and both residents were unable to recall how or why they were in bed together. The male resident later reported that the woman had wandered into his room, sat on his bed, and would not leave despite his requests, and he stated that he did not lie in bed with her or do anything with her. The facility’s failure to prevent the high-risk, cognitively impaired resident from wandering into another resident’s room resulted in both residents being found in bed together and the male resident being inappropriately exposed.
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