Failure to Update Care Plan and Interventions for Resident with New Wandering Behaviors
Penalty
Summary
The facility failed to identify and address accident risks for a resident who developed wandering behaviors and confusion. Despite multiple progress notes documenting the resident's confusion, wandering in the hallways, entering other residents' rooms, and searching for family members, the resident's care plan and Kardex were not updated to reflect these new behaviors. The resident, who had severe cognitive loss as indicated by a BIMS score of 4, legal blindness, and a diagnosis of memory loss, was observed by staff and other residents to be disoriented and in need of frequent redirection. The care plan interventions focused on fall risk and pain management, but did not address the resident's wandering or entry into other residents' rooms. Staff interviews confirmed that the resident did not have a history of wandering upon admission, but began exhibiting these behaviors during their stay. The facility's policy required that elopement and wandering risks be assessed and communicated to staff, and that care plans be updated accordingly. However, the resident's risk evaluation and care plan were not revised in response to the observed wandering and confusion, and staff were not made aware of these new risks through the Kardex. This lack of timely assessment and intervention resulted in the failure to prevent potential accidents related to the resident's wandering behavior.