Failure to Timely Update Care Plan for High-Risk Wandering and Elopement
Penalty
Summary
The facility failed to develop and update a care plan with appropriate interventions for a resident identified as high risk for wandering and elopement. Despite multiple assessments and incident reports indicating the resident's ongoing high risk and actual incidents of wandering and elopement, the care plan was not revised in a timely manner to address these risks. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and mobility abnormalities, was repeatedly observed ambulating throughout the facility and was even found outside the building on one occasion. Documentation showed that the resident's risk for wandering was consistently high, as reflected in several wandering risk scale assessments. The care plan initially did not address the resident's high risk for wandering and elopement, and only included interventions for diversionary activities. No updates or changes were made to the care plan following incidents of exit-seeking behavior and actual elopement until several months after admission. Staff interviews confirmed that there was a lack of care plan updates and intervention changes, and the DON acknowledged that the absence of a care plan coordinator contributed to the delay in updating the care plan to reflect the resident's needs.