Failure to Consistently Implement Enhanced Monitoring for a Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and consistent implementation of an identified safety intervention for a resident with severe cognitive impairment and a history of wandering and falls. The resident, admitted with diagnoses including anemia, dementia, and hypothyroidism, had an Annual Minimum Data Set documenting severely impaired cognition and a need for supervision with transfers and ambulation. The resident’s fall risk care plan identified risk factors such as confusion, gait and balance problems, incontinence, and vertigo, and included an intervention for enhanced monitoring for safety initiated after an incident in which the resident was found with a forehead hematoma of unknown origin. On the date of the incident, documentation showed that a CNA last provided care to the resident in the late afternoon and last observed the resident in bed about an hour before the resident was later found with a forehead hematoma, with no staff able to identify when or how the injury occurred. The resident was evaluated in a hospital emergency department, where multiple imaging studies, including CT scans of the head and cervical spine and X‑rays of both knees and the pelvis, revealed no abnormalities, and the resident returned to the facility with continued neurological checks. Interviews with CNAs, an LPN, and the resident’s roommate consistently described the resident as frequently walking around the secure unit, entering other residents’ rooms, not remaining in bed, and being difficult to redirect without becoming upset. Despite the care plan intervention for enhanced monitoring for safety, staff interviews revealed inconsistent understanding and implementation of this intervention. One LPN stated that the resident was not on enhanced monitoring checks for safety and was only on a wandering checklist signed once per shift. The DON confirmed that the resident ambulated independently on the unit, was not accompanied by staff, and that no staff witnessed the incident resulting in the forehead hematoma. Review of the Enhanced Monitoring Rounding Tool for the period following initiation of enhanced monitoring showed multiple missing staff initials and blank Unit Manager/Supervisor signature lines, demonstrating that the facility did not consistently document or verify completion of the enhanced monitoring intervention as required by facility policy and the resident’s care plan.
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