Failure to Adequately Supervise and Manage Intrusive Wandering in a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, treatment, and services for a resident with dementia who exhibited intrusive wandering behaviors into other residents’ rooms. The resident had diagnoses of dementia, Alzheimer’s disease, hypertension, and unspecified protein-calorie malnutrition, with a Quarterly MDS documenting severe cognitive impairment, physical behavioral symptoms toward others, and frequent wandering. The resident’s care plan identified a potential for physical aggression related to dementia, triggers such as abrupt approaches, and interventions including redirection, distraction, offering snacks, and documenting behaviors and interventions. Despite this, the resident’s behavior log and care planning adjustments in response to ongoing intrusive wandering and room entries were not described, and the resident continued to enter other residents’ rooms uninvited and sometimes partially clothed. Multiple residents reported specific incidents of this resident entering their rooms and not leaving when asked. One resident reported that the wandering resident entered her room wearing only a diaper and had to be told to leave. Another resident stated that the wandering resident came into her room in a wheelchair, requiring her to get out of bed and physically push the resident out. A further resident reported keeping her bed in a high position so the wandering resident could not get into it, and another incident where she awoke to the resident touching her foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged that the resident wandered into other rooms and described efforts to redirect, offer snacks and fluids, and engage the resident in activities, but the resident did not consistently stay at activities and remained “on the go.” The facility’s dementia clinical protocol required the IDT to identify the resident’s level of support, review changing needs, and adjust interventions as needed, but the ongoing intrusive wandering and repeated room entries showed that the resident’s behaviors continued despite these general redirection efforts, leading to the cited deficiency in supervision and behavioral management.
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