F0684

E

Failure to Document and Monitor Change in Resident Wandering Behavior

Lancaster, California Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of nursing practice in response to a resident’s new wandering behavior. Resident 1, admitted with diagnoses including type 2 diabetes mellitus, COPD, and cerebral infarction, had a prior Wandering/Elopement Risk Evaluation dated 2/18/2026 indicating no risk for wandering or elopement. The resident’s H&P dated 2/19/2026 documented fluctuating capacity to understand and make decisions, while an MDS dated 2/25/2026 indicated intact cognitive skills for daily decision making. On 3/13/2026, Resident 1 was reported wandering into another resident’s room multiple times, which represented a change from the resident’s prior status.

On 3/13/2026, Resident 2, who was cognitively intact, reported that Resident 1 entered her room three times, and stated that Resident 3 reported these incidents to a licensed nurse. LVN 1 confirmed that Resident 3 reported Resident 1 being inside the rooms of Residents 2 and 3 and stated that this wandering behavior was new for Resident 1. LVN 1 reported the incident to the licensed nurse in charge of Resident 1 on the 11 p.m. to 7 a.m. shift. However, there was no Change of Condition (COC) Evaluation form completed for Resident 1 on 3/13/2026, and there was no documented evidence that the attending physician or the resident’s family member were notified of this new wandering behavior, despite facility policy requiring immediate consultation with the physician and notification of the resident representative when there is a significant change in physical, mental, or psychosocial status.

Further record review and interviews showed that the facility did not document ongoing assessment and monitoring of Resident 1 following this change in condition. LVN 3 stated that Resident 1’s wandering behavior was a change in condition and that the resident should have been monitored every shift for 72 hours, but Resident 1’s progress notes lacked documentation of monitoring on multiple shifts on 3/14/2026, 3/15/2026, and 3/16/2026. LVN 3 and the DON both acknowledged there was no confirmed documented evidence of monitoring on these identified shifts. The facility’s Documentation Policy required initiation of 72-hour charting for a significant change in physical, mental, or psychosocial status, and the Notification of Changes policy specified use of the SBAR charting form as the documentation of a resident’s change in condition. These policies were not followed for Resident 1’s new wandering behavior.