Failure to Develop and Implement Comprehensive Care Plan for Resident at Risk of Falls and Elopement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing falls, intrusive wandering, and elopement for a resident with advanced Alzheimer's disease and dementia who was on hospice care. Despite multiple documented incidents, including falls, exit-seeking behavior, and intrusive wandering into other residents' rooms and administrative offices, there was no care plan in place with interventions specific to these risks. The resident had a history of 1 to 2 falls in the past three months, was observed attempting to leave the facility, and was noted to be restless and pacing, often entering other residents' rooms and moving items into the hallway. Staff observations and medical record reviews indicated repeated episodes of unsafe wandering, falls, and attempts to exit the facility, with interventions such as a wander guard being implemented reactively rather than as part of a documented, proactive care plan. The facility's own policy required the development of a comprehensive, person-centered care plan with resident-specific interventions, but this was not completed for the resident in question, as confirmed by the review of care plans and interviews with facility staff.