F0607

E

Failure to Implement Abuse-Prevention and Wandering Policies for Resident-to-Resident Incidents

Kennewick, Washington Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its written abuse-prevention and unsafe wandering policies to identify, protect, and prevent abuse related to one resident’s repeated entry into other residents’ rooms and inappropriate contact. The facility had policies stating it would implement interventions to mitigate unsafe wandering, including wandering into other residents’ rooms, and that it would identify, assess, care plan, and monitor residents with behaviors that may lead to conflict, as well as ensure ongoing safety and protection for alleged victims and other residents. Despite these policies, Resident 1, who had dementia with severe agitation, anxiety, depression, severe cognitive impairment, and dependence on staff for ADLs, was repeatedly documented as wandering freely through the halls and into other residents’ rooms over multiple days. Progress notes described Resident 1 entering many rooms, being difficult to redirect, and causing other residents to feel uncomfortable or upset, with some residents requesting physical barriers such as stop sign barricades across their doorways.

Staff interviews confirmed that Resident 1 frequently wandered and entered other residents’ rooms, and that the primary response was to redirect them back to their hall or room. Staff reported that Resident 1 had grabbed other residents’ belongings and that barricades were placed across some doorways to try to prevent entry. The Activities Director stated that Resident 1 constantly wandered into rooms, that these incidents upset some residents, and that female residents were more concerned due to feeling more vulnerable and Resident 1’s tall, dominant appearance. The Activities Director also described an incident in which Resident 1 followed them, placed hands on their forearms, and stated, “you are not going to like what I am about to do,” requiring assistance from other staff to move Resident 1 away. Other staff, including NAs and a maintenance assistant, acknowledged that Resident 1’s presence in rooms scared residents, but some did not recognize these events as suspected abuse and did not report residents’ fear to nursing or management.

Multiple residents described specific incidents involving Resident 1 that were not effectively addressed under the abuse-prevention policy. One resident with intact cognition, diabetes, COPD, and heart failure reported that Resident 1 approached them at a nurse’s station, grabbed their left breast after a greeting, and had to be escorted away by staff. Another resident with PTSD, anxiety, and depression, who required assistance with ADLs and had intact cognition, reported that Resident 1 entered their room on more than one occasion, sat on their bed, pulled up their blanket, and looked at their legs, which made them feel scared, especially given their history of sexual trauma. A third resident with heart failure, anxiety, depression, and intact cognition stated that Resident 1 entered their room multiple times, refused to leave when asked, and made them feel unsafe and afraid to the point that they called the police. Staff interviews indicated that Resident 1 was “very difficult to watch,” that one-to-one supervision was believed necessary by some staff, and that management had been informed of residents’ fears. The DON and Administrator later acknowledged that the initial investigation into a resident-to-resident altercation involving Resident 1 was not completed correctly and that the correct process for implementing abuse prohibition policies had not been followed, resulting in a failure to identify and protect residents from potential abuse and psychosocial harm as required by facility policy and WAC 388-97-0640(1)(2)(6)(b).