Failure to Update Care Plan After Elopement Incident
Penalty
Summary
The facility failed to review and revise the care plan for a resident following an elopement incident. According to facility policy, comprehensive care plans are to be updated by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and with any new or changed interventions. An incident report documented that a resident was found ambulating across the parking lot after leaving the building through an ambulance door without the door alarm sounding. Immediate interventions, including 15-minute visual checks on the resident and hourly checks on door alarms, were initiated. However, the resident's care plan, which already listed a risk for elopement, was not updated to reflect the incident or the new interventions. The ADON confirmed that the care plan did not include the elopement event or the additional monitoring measures implemented after the incident.