Failure to Develop and Implement Elopement Care Plan for Resident with Psychosis and Schizophrenia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing elopement risk for a resident with a history of psychosis and schizophrenia. The resident was admitted with significant mental health diagnoses, including psychosis and schizophrenia, which are associated with symptoms such as hallucinations, delusions, and disorganized thinking. Despite these risk factors, the clinical record review showed that no care plan was in place to address the resident's risk of elopement. On April 23, 2025, the resident was discovered missing from his room, prompting a search and notification of local authorities, facility administration, and the resident's guardian. The resident was later found at a local convenience store and returned to the facility without injury. Interviews with the resident revealed ongoing dissatisfaction with the facility environment and food, as well as a stated intent to leave again if possible. The Administrator and DON confirmed that the care plan was not comprehensive regarding elopement prevention and resident safety.