F0740

E

Failure to Provide Adequate Behavioral Health Services and Supervision on Dementia Unit

Byram, Mississippi Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary behavioral health services by qualified staff to support dignity, privacy, safety, and psychosocial well-being for multiple residents on a dementia unit. Facility policy on dementia care required person-centered care, individualized non-pharmacological approaches, and services that maximize dignity, autonomy, privacy, socialization, independence, choice, and safety. Despite this, one resident with severe cognitive impairment, Pick’s disease, Alzheimer’s disease, anxiety, and a history of falls repeatedly wandered into other residents’ rooms, lay in their beds, removed their belongings, and displayed aggressive behaviors such as yelling, hitting, and growling at staff and residents. Progress notes and incident reports documented numerous episodes over several months, including entering rooms uninvited, sleeping in other residents’ beds, urinating in other residents’ rooms and in the hallway, attempting to take other residents’ food, and physically attacking another resident.

The records show that several other residents with dementia or cognitive impairment were directly affected by these behaviors. One resident with severe cognitive impairment and a history of falls was involved in an incident in which another resident entered her room and got into her bed; another resident with severe cognitive impairment and hemiplegia fell during an intrusion by the same wandering resident, as reported in a progress note. A cognitively intact resident with dementia and depression experienced an incident in her room when the wandering resident exited her bathroom and moved toward her, resulting in physical contact between their hands. Another severely cognitively impaired resident with Alzheimer’s disease and a history of falls was also identified as having her room and bed entered by the same resident, including an episode where he got into her bed while she was out of the room.

Interviews with staff, the administrator, the DON, the ADON, the SSD, a complainant, and a resident representative confirmed that wandering into other residents’ rooms was common on the dementia unit and that the specific resident’s behaviors were recurrent and known to the facility. Staff acknowledged that care instructions for this resident included supervision and monitoring for safe wandering, and leadership stated that residents with wandering behaviors required close monitoring and that staff were trained to intervene when a resident attempted to enter another resident’s room or invade their privacy. The complainant and the resident representative expressed concern about the adequacy of supervision, particularly during evening and night shifts, and described episodes where residents appeared frightened or refused to enter their own rooms due to the intruding resident’s presence. The DON further acknowledged that individualized, non-pharmacological interventions specific to this resident, such as ensuring access to personal entertainment devices and visual cues to help him identify his own room and bathroom, had not been incorporated, despite awareness of his repeated intrusive and aggressive behaviors toward other residents.

Overall, the documented incidents, resident records, and interviews demonstrate that the facility did not effectively implement its dementia care policy or provide sufficient behavioral health services and supervision to prevent repeated intrusions, aggression, and privacy violations affecting multiple residents. The failure to consistently monitor and redirect the wandering resident, to prevent him from entering other residents’ rooms and using their belongings, and to implement identified individualized non-pharmacological interventions contributed to ongoing episodes that compromised the dignity, privacy, and psychosocial well-being of at least five residents on the dementia unit.