BIRMINGHAM, AL - Federal inspectors cited Birmingham Nursing and Rehabilitation Center for failing to prevent a resident with severe dementia from wandering into another resident's room, resulting in a physical altercation between the two residents.
The March 2025 inspection, conducted in response to a complaint, revealed that the facility had not implemented adequate behavioral interventions to manage a resident's wandering behaviors despite knowing about the issue for months.
Dementia Resident's Dangerous Wandering Pattern
The incident involved a resident with severely impaired cognition who had been diagnosed with dementia, Alzheimer's disease, and mood disorders. According to federal inspection records, this resident had a documented history of wandering into other residents' rooms, with staff aware of the behavior since at least September 2024.
The facility's own care plan, initiated on September 17, 2024, identified the resident's "behavior wandering into other resident's room" as a focus area. However, the intervention strategy was limited to basic monitoring and documentation, with the goal simply stated as "the resident's safety will be maintained."
The shared bathroom design between the two residents' rooms contributed to the confusion. Staff reported that the bathroom doors confused the wandering resident, who would enter through one door and exit through the other, leading directly into another resident's private space.
Physical Altercation in Resident's Bedroom
On October 30, 2024, the wandering incident escalated into a physical encounter. According to the facility's investigative summary, the confused resident entered another resident's room through the shared bathroom. The room's occupant, who had intact cognition, became distressed and yelled at the intruder to leave.
A certified nursing assistant responded to the yelling and found the wandering resident standing near the head of the other resident's bed. The room's occupant reported that the confused resident had slapped them on the forehead during the encounter.
In a witness statement dated October 31, 2024, the affected resident described the incident: "did not mean any harm. (He/she) came out of the bathroom the wrong way and tried to get in bed with me. I tried to push (him/her) away and (he/she) slapped me. (He/she) did not mean any harm though."
The situation was defused when staff separated the residents and returned the confused individual to their own room. Medical assessments conducted immediately after the incident revealed no physical injuries to either resident.
Previous Wandering Episodes Documented
Federal inspectors discovered this was not an isolated incident. A licensed practical nurse interviewed during the inspection recalled that the wandering resident had experienced two episodes of entering other residents' rooms, including the October incident and another occurrence approximately six weeks earlier.
The nurse explained that during the October incident, the confused resident wandered into the wrong room thinking it was their own bed and attempted to get into bed with another resident. Following that earlier incident, the facility implemented interventions focused on observing the resident more frequently and providing bathroom assistance.
Despite these measures, the facility's own administrator acknowledged during interviews that the interventions implemented in September 2024 were "not necessarily" effective in preventing future wandering episodes.
Inadequate Behavioral Intervention Strategy
Federal inspectors found that the facility's approach to managing the wandering behavior fell short of established standards for behavioral health care. The facility's own policy required the development of individualized behavioral interventions for residents displaying behaviors that could potentially harm themselves or others.
The policy defined behavioral interventions as "individualized non-pharmacological approaches to care" that should be "directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities."
However, the care plan interventions for the wandering resident were limited to basic monitoring and documentation, without addressing the root causes of the behavior or implementing environmental modifications to prevent future incidents.
When interviewed, the administrator expressed concern about the situation, stating that "it was a concern when residents with behaviors that had a potential to harm to other residents were not monitored which could lead to incidents of abuse."
Medical Factors and Risk Assessment
The wandering resident's condition presented significant safety risks that required specialized management. With a Brief Interview for Mental Status score of only 2 out of 15, indicating severely impaired cognition, the resident was unable to orient themselves properly within the facility.
Dementia-related wandering is a well-documented behavioral symptom that affects up to 60% of individuals with the condition. This behavior poses serious safety risks in institutional settings, including the potential for falls, getting lost, and confrontations with other residents or staff.
The facility discovered during their post-incident investigation that the wandering resident had developed a urinary tract infection, which can significantly worsen confusion and behavioral symptoms in individuals with dementia. Treatment for the infection was initiated on October 31, 2024.
Facility Response and Corrective Actions
Following the October incident, Birmingham Nursing and Rehabilitation Center implemented a series of immediate and ongoing corrective measures. The facility provided one-on-one supervision for the wandering resident until they could be assessed by behavioral health specialists on October 31, 2024.
Environmental modifications included placing a stop sign on the affected resident's door and adding the wandering resident's name inside their bathroom to help with orientation. The facility also conducted behavior meetings to update care plans and initiated comprehensive monitoring protocols.
The facility's Quality Assurance and Performance Improvement program implemented enhanced oversight, including behavioral monitoring audits five times per week for two weeks, followed by three times per week for two additional weeks, then weekly monitoring.
Staff education was completed on November 10, 2024, covering both behavior management policies and abuse prevention protocols. The training emphasized that all behavioral symptoms with potential to harm other residents required immediate intervention.
Regulatory Compliance and Industry Standards
The citation under Federal regulation F740 requires nursing homes to provide necessary behavioral health care and services to each resident. This includes developing appropriate interventions to manage behaviors that could affect resident safety or well-being.
Industry best practices for managing wandering behavior in dementia care include environmental modifications, structured activities, consistent routines, and individualized behavioral interventions based on the underlying causes of the wandering.
Federal inspectors determined that while the facility's corrective actions implemented between October 30 and November 10, 2024, were comprehensive and ongoing monitoring appeared effective, the initial failure to prevent the incident represented a deficiency in behavioral health care provision.
The facility's plan included continued monitoring through January 2025, with quality assurance reviews to evaluate the effectiveness of implemented interventions and prevent future incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birmingham Nursing and Rehabilitation Ctr LLC from 2025-03-26 including all violations, facility responses, and corrective action plans.
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