Failure to Timely Update Care Plans for Elopement Risk and Departure Alert Systems
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing elopement risk and the use of a departure alert system for two residents identified as exit seeking. Both residents had documented histories of wandering and were assessed as being at risk for exit seeking/wandering, as evidenced by multiple behavioral notes and formal assessments. Despite these findings, their care plans did not reflect their elopement risk or the use of departure alert systems until a much later date, even after incidents such as one resident being found wandering near a door with the alarm sounding. Physician orders for the use of departure alert systems were not placed until after these risks and behaviors had been documented, and the care plans were only updated following the placement of these orders. Staff interviews confirmed that the care plans were not updated to include elopement risk and interventions until the physician's orders were in place, despite facility policy indicating that cognitive assessments and activity logs should inform individualized service plans. This delay resulted in a lack of timely, comprehensive care planning for residents at risk of elopement.