Failure to Care Plan for Resident Wandering and Room Intrusions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with specific, measurable interventions to address a resident’s wandering behavior, particularly entering other residents’ rooms. The resident was originally admitted with dementia with behavioral disturbance, anxiety disorder, vascular dementia, and confusional arousals. An MDS dated 1/22/2026 documented severely impaired cognitive skills and a need for moderate assistance with ADLs, but did not code the resident as wandering in a manner that significantly intruded on others. An IDT note dated 02/09/2026 described an altercation on 02/08/2026 in which the cognitively impaired, disoriented resident independently ambulated to a roommate’s bedside, attempted to pull up the roommate’s blanket, and entered the roommate’s personal space, leading the roommate to become verbally upset and strike the resident in the left eye. A psychiatric assessment dated 02/12/2026 documented that the resident was profoundly confused, severely disoriented, had limited insight, functioned at an extremely low cognitive level consistent with advanced dementia, and did not understand boundaries or the seriousness of certain behaviors. The Social Services Director reported that the resident had a low BIMS score, could not answer simple questions such as name and time, and required staff redirection because the resident always wandered into other residents’ rooms. RN staff confirmed the resident was very confused, wandered into both female and male residents’ rooms, and required redirection, and also stated there were no care plan interventions or specific interventions in place to address this wandering behavior and no staff member assigned to monitor it, despite complaints from female residents. The MDS coordinator confirmed that no care plan had been developed to address the resident’s wandering into other residents’ rooms and that there were no individualized interventions in place, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents’ needs.
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