Failure to Act on Resident Council Concerns About Wandering Residents Entering Rooms
Penalty
Summary
The facility failed to honor residents' rights to have their views considered and acted upon regarding ongoing concerns about confused, wandering residents entering other residents' rooms. Facility policy stated that the Activity Director would attempt to accommodate resident recommendations and provide follow-up to the Resident Council, and that resident issues would be documented and forwarded to the Administrator for appropriate follow-up. Resident Council minutes over three consecutive months documented repeated concerns: in December, residents reported confused residents going into other rooms late at night with no resolution documented; in January, residents again reported wandering and removal of items from rooms, with a documented plan for staff education and purposeful rounding; and in February, the minutes did not show any review or follow-up of the prior wandering concern to determine if it had been resolved. Residents later reported that they had suggested using stop signs across doorways during a council meeting but had not received any response or implementation. Multiple resident interviews corroborated that the problem persisted. One resident reported that residents moved from the dementia unit to another hall were confused, roamed hallways, entered her room, and became more agitated and hostile when redirected; she described an incident where a confused resident grabbed her wheelchair from behind and began pushing her until staff intervened. Other residents reported that confused residents roamed into their rooms, attempted to take items that did not belong to them, and took food from meal trays. A bedbound resident stated that a confused resident frequently entered her room, appeared to mistake her for a family member, and took her snacks, and she had not completed a grievance form. In a group interview, several residents stated that wandering residents entered their rooms daily, hit and stole from residents, and that staff response was limited to telling the wandering residents to move on. Residents also reported that, despite raising these issues monthly since December and suggesting stop signs for doors, they had not received the signs or any substantive response from administration, demonstrating a failure to act promptly on resident council concerns about quality of life and wandering behaviors.
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