F0600

D

Failure to Implement Effective Wandering Interventions Resulting in Resident-to-Resident Altercation

Banning, California Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement effective interventions to prevent resident-to-resident physical altercations, specifically related to a resident with known wandering and impulse control issues. One resident with intact decision-making capacity reported that another resident entered his room, attempted to take his cup and blanket, and then punched him twice in the face when he tried to stop the behavior. As a result, he sustained swelling of the right upper lip and a scratch on the nose. He stated that he pressed his call light but did not receive an immediate staff response and had to yell for help before staff intervened.

The resident who initiated the altercation had documented diagnoses of delusional disorder and impulse disorder and was noted in the medical record to be unable to make decisions. The care plan for this resident, dated several months prior, identified risk for elopement and wandering related to altered cognitive status and forgetfulness, with a goal that the resident’s safety would not be endangered by these behaviors. However, the care plan only contained a general intervention for elopement/wandering and did not specify the type or level of supervision or monitoring needed to address the resident’s wandering behavior. A physician’s order in the eMAR directed staff to monitor this resident for episodes of impulse control disorder manifested by wandering and danger to self and others, but there was no documentation that such behaviors were monitored or addressed on the date of the incident.

Staff interviews further showed gaps in implementation and communication of interventions for the wandering resident. The DON acknowledged that the care plan for elopement and wandering lacked specific prevention interventions and that there was no CNA documentation that monitoring of wandering behavior had been completed. The DON also stated that the internal communication board did not list this resident as at risk for wandering prior to the incident. Nursing staff, including an LVN and the charge RN on duty at the time of the altercation, reported awareness of the resident’s history of wandering into other residents’ rooms and occasional aggression, but were unaware of any written interventions to address this behavior. A CNA assigned to the wandering resident on the evening of the incident stated that the resident frequently wandered and needed to be checked every 15 to 30 minutes, and that while she was on her lunch break, no one was assigned to check on the resident, during which time the altercation occurred.