Failure to Develop and Implement Care Plan for Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to address exit-seeking behavior for a resident with severe cognitive impairment and a history of hepatic encephalopathy, schizophrenia, and bipolar disorder. Despite multiple documented episodes of the resident attempting to leave the secured, locked unit, including instances where the resident was able to exit the unit and required staff intervention to return, there was no care plan in place to address these behaviors. Facility policy required that residents at risk for wandering or elopement have care plans with strategies and interventions to maintain safety, but this was not followed for this resident. Staff interviews confirmed that the resident's exit-seeking behavior was frequent, often occurring daily and intensifying in the afternoons. Staff reported using redirection, which was often ineffective, and acknowledged that the resident was able to move quickly and reach exit doors multiple times a day. Nursing and social services staff, as well as facility leadership, confirmed that the resident's care plan did not address these behaviors, despite awareness of the ongoing risk and facility expectations for care planning in such cases.