F0656

D

Failure to Implement Care Plan Interventions for Wandering Resident

Harrisburg, Pennsylvania Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement a comprehensive care plan for a resident with dementia, muscle weakness, and lack of coordination. The resident’s care plan, initiated on January 27, 2026, identified behavioral symptoms of wandering throughout hallways and occasionally into other residents’ rooms. Planned interventions included providing visual deterrents such as stop signs, warning signs, arrows, or do not enter signs; removing the resident from other residents’ rooms and unsafe situations; and assessing for comfort measures and basic needs when wandering began. Facility policy required that all staff caring for a resident be familiar with and follow the resident’s plan of care.

Surveyor observations on multiple days showed that these interventions were not carried out. On March 9, 2026, the resident was observed wandering from room to room, entering another resident’s room, picking up that resident’s Styrofoam water cup, and dropping it on the floor, while three nurse aides were present in the hallway and did not intervene or redirect the resident. One nurse aide acknowledged seeing the incident and later stated that the resident always wanders room to room and made no attempt to redirect her. On March 10, 2026, during an activity near the nurse’s station, the resident was again observed wandering the hall and closing open resident room doors without redirection from a nurse and a nurse aide present. Additionally, during observations from March 9–12, 2026, no visual deterrents such as stop signs or warning signs were present on the hallway where the resident resided, and the Regional Director of Clinical Services confirmed that such signs had not been placed despite the care plan requirements.