Failure to Develop Comprehensive Care Plans for Residents with Elopement Risk and Wound Vac Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents as required. For one resident with severe cognitive impairment who utilized a wheelchair, clinical records indicated an incident where the resident was found on the ground floor attempting to leave the building. An elopement evaluation identified this resident as being at risk for elopement, with documented behaviors such as a history of attempted leaving, verbalizing a desire to go home, packing belongings, and wandering near exit doors. Despite these findings and the application of an Alpha Watch device, there was no care plan addressing the resident's exit-seeking behavior. For another resident, observations and physician orders confirmed the continuous use of a wound vac for a sacral wound, with specific instructions for device settings, placement checks, and canister changes. However, a review of the care plan revealed that it did not include a comprehensive plan of care for the use of the wound vac. Interviews with the Nursing Home Administrator confirmed that care plans addressing these specific needs were not developed for either resident.