F0744

D

Failure to Individualize Dementia Care and Care Plan for Wandering Behavior

El Cajon, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide individualized dementia care and care planning for a resident with dementia and schizophrenia whose behavior included wandering into other residents’ rooms. Resident 6 was admitted and later readmitted with diagnoses of unspecified dementia and schizophrenia, was documented as lacking capacity to make decisions, and had a court-appointed decision maker. An MDS assessment showed significant cognitive impairment, and the history and physical confirmed the resident did not have capacity to understand and make decisions. Staff documentation, including an SBAR summary, noted that the resident was going into another resident’s room and slamming doors, and that the resident was hard to redirect despite calm approaches, explanations, and encouragement.

On the day of the altercation, nursing documentation indicated that Resident 5 was ambulating down the hallway when he approached Resident 6, began yelling, and grabbed Resident 6’s arm. Before staff could intervene, Resident 6 struck Resident 5 in the face, causing Resident 5 to fall to the ground. Staff interviews revealed that Resident 6 frequently wandered into other residents’ rooms, was very confused, and was easily startled, reacting physically when grabbed. One CNA reported that Resident 6 had been inside Resident 5’s room most of the day, that she had redirected him multiple times without success, and that she informed a licensed nurse that the resident was not responding to redirection. Staff also reported that Resident 6 had put on Resident 5’s clothing and that this situation would have triggered Resident 5’s aggression.

Despite these known behaviors and staff observations, a review of Resident 6’s care plans for elopement and cognitive impairment related to dementia showed that the behavior of wandering into other residents’ rooms was not identified or addressed with individualized interventions. The Director of Staff Development and the Assistant Director of Nursing acknowledged that Resident 6 was known to wander into other residents’ rooms and that such behavior, including rummaging or taking things, could lead to altercations and incidents of abuse. They confirmed that even after the altercation between Resident 6 and Resident 5, Resident 6’s wandering into other residents’ rooms had not been identified, assessed, or incorporated into the resident’s care plan with resident-specific interventions, contrary to the facility’s dementia and resident-to-resident altercation policies.