Failure to Accurately Assess and Care Plan for Elopement Risk
Penalty
Summary
Licensed nurses failed to accurately complete an elopement and wandering risk assessment for a resident with severe cognitive impairment and multiple diagnoses affecting cognition, including cerebral palsy, chromosomal abnormality, and developmental delay. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and there was a documented incident where the resident eloped from the facility during a shift change. However, the elopement and wandering risk assessment did not reflect the resident's diagnoses, with relevant sections left blank or incorrectly marked, and the assessment did not indicate the presence of cognitive-impacting diagnoses. Additionally, there was no care plan developed to address elopement or wandering risks for the resident, despite facility policy requiring care plans for residents identified as at risk. Both the assistant director of nursing and the licensed vocational nurse who completed the assessment confirmed that the documentation was inaccurate and incomplete. Facility policies reviewed stated that residents at risk for wandering or elopement should have care plans with strategies and interventions to maintain safety, which was not done in this case.