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F0656
D

Failure to Develop Care Plan for Resident at Risk of Wandering and Elopement

Glendale, California Survey Completed on 05-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A comprehensive, person-centered care plan was not developed for a resident who was assessed to be at risk for wandering and elopement. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and cognitive communication disease, was documented as having severe cognitive impairment and requiring moderate to substantial assistance with mobility and self-care. The resident's Elopement Evaluation indicated a risk for wandering and elopement, and staff interviews confirmed that the resident wandered around the facility and was at risk for elopement. Despite these assessments and observations, a review of the resident's active care plans revealed that no care plan had been initiated to address the behaviors of wandering or risk of elopement. The Director of Nursing acknowledged the absence of such a care plan and stated that interventions should have been included to inform staff of specific actions to take. The facility's policy required care plans to include measurable objectives, timeframes, and interventions addressing the underlying sources of problem areas, but these requirements were not met for this resident.

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