Failure to Develop and Implement Comprehensive Elopement Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents identified as being at risk for elopement. Multiple residents, as determined by their Elopement Risk Evaluations, were found to be at risk, yet their care plans either lacked appropriate interventions or were not initiated in a timely manner. For example, one resident with a high elopement risk score had a care plan that included the use of a WanderGuard device, but there were no corresponding physician orders to monitor the device's placement and function until after the survey date. Staff interviews revealed a lack of awareness regarding which residents were at risk and whether interventions such as WanderGuard were in place or being monitored as required by facility policy. Other residents who were identified as at risk for elopement did not have any elopement care plans in place at the time of review, despite their risk status being documented. Staff members, including nursing assistants, LPNs, and RNs, consistently stated that residents at risk for elopement should have individualized care plans, yet these were missing or delayed for several residents. In some cases, care plans were only initiated after the survey process had begun, indicating a lapse in timely care planning and implementation. Facility policies required individualized, interdisciplinary care plans for residents at risk of elopement, as well as specific monitoring protocols for devices like WanderGuard. However, the review of records and staff interviews demonstrated that these policies were not consistently followed. The lack of timely and comprehensive care planning for residents at risk of elopement resulted in unmet care needs and the potential for negative outcomes, as staff were not always aware of residents' risk status or the interventions required to ensure their safety.