F0744

D

Failure to Adequately Monitor and Manage Dementia-Related Wandering and Behaviors

New Castle, Indiana Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately monitor and treat a resident’s dementia-related wandering and behavioral symptoms in accordance with its dementia care policy. Resident C was admitted with diagnoses including dementia with agitation and anxiety and was documented on admission as confused and combative. Within minutes of arrival, he refused to wait for a physical therapy evaluation, would not follow staff direction, moved into his roommate’s area, handled the roommate’s belongings, and made physical contact with the roommate. Verbal redirection was unsuccessful, and he became physical, striking staff. Later that evening, he and his roommate were screaming at each other, leading staff to temporarily move him to another room. During this period, he continued to leave his room, wander into other residents’ rooms, and remain physically combative with staff.

The facility did not have Resident C’s discharge medications, including his scheduled Risperidone, available upon admission, and emergency medication obtained that night had little to no effect. His medications were not available until his second day at the facility. During this time, multiple female residents voiced that they wanted him kept away from them. Behavior notes documented that he was confused, ambulating in the hallways, refusing to stay in his bed despite repeated attempts, and wandering without purpose. He rummaged through his roommate’s belongings and irritated his roommate. Staff interviews confirmed that he repeatedly entered other residents’ rooms, was difficult to redirect, and was combative when staff attempted to intervene. One CNA reported that it was chaotic when he was not provided one-on-one supervision and that he wandered into other residents’ rooms, including climbing into bed with another resident as reported in shift report.

Multiple residents described specific incidents of Resident C entering their rooms uninvited. One resident reported that he came into her room, shut the door, removed her wheelchair foot pedals from the bed, asked where to put them, and ultimately placed them in the trash before leaving. On another occasion, he lay on her bed until staff redirected him. Another resident stated that he entered her room, closed the door, sat on the empty bed, turned back the covers, made inappropriate hand signs, and told her to “shut up,” which left her feeling scared and uncomfortable. Behavior notes further documented that he continued to enter other residents’ rooms, strike staff during redirection attempts, spit on a nurse, lay on the floor at the nurse’s station, and exhibit exit-seeking behavior. Staff, including the Social Services Director and Administrator, acknowledged that he wandered everywhere, went into other residents’ rooms, and was aggressive with staff, and that he was not placed on one-on-one supervision until several days after admission, despite ongoing behaviors and resident complaints. These actions and inactions demonstrate the facility’s failure to provide appropriate monitoring and dementia care services to address his wandering and behavioral symptoms as required by its own dementia care policy.

Additional documentation showed that Resident C wandered the facility for entire shifts, entered multiple residents’ rooms, upset residents, and at one point sat on another resident’s bed, removed his pants and socks, and attempted to lie down while the room’s occupant became angry and told him to leave. Staff required multiple attempts to redirect him from these rooms. Residents reported feeling uncomfortable and, in at least one case, scared by his presence and behavior in their rooms. The Social Services Director stated that the facility had believed he was not ambulatory and was surprised by his ability to walk everywhere upon admission, and also noted that he was more confused when off his original hospital medications. Despite the facility’s dementia care policy requiring assessment, individualized care planning, person-centered non-pharmacological approaches, environmental modifications, and ongoing monitoring of interventions for effectiveness, the record and interviews show that Resident C’s wandering and intrusive behaviors into other residents’ rooms persisted over several days without timely implementation of effective monitoring and supervision.

The Administrator confirmed that Resident C wandered into other residents’ rooms and was aggressive with staff, and that other residents were upset because they were not used to residents entering their rooms. Staff accounts and behavior notes consistently described ongoing wandering, room entries, combative behavior, and difficulty with redirection over multiple days following admission. The delay in obtaining his scheduled psychotropic medications, the lack of immediate and sustained one-on-one supervision despite repeated incidents, and the continued reports from residents and staff about his intrusive and aggressive behaviors collectively demonstrate the facility’s failure to provide appropriate treatment and services for a resident with dementia-related wandering and behavioral symptoms, as required by its dementia care policy and regulatory standards.