Failure to Develop and Implement Person-Centered Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan for a resident with dementia, depression, and hypertension after the resident eloped from the facility. The resident was found off facility grounds in his wheelchair by two individuals from a nearby church and was returned to the facility. Documentation showed that this was the first time the resident had eloped, and he stated he left because he wanted to go outside due to the warm weather. At the time of observation, the resident was confused and forgetful, with cognitive status varying from intact to moderately impaired according to recent assessments. Review of the care plan revealed that the interventions listed, such as disguising exits and taping floors, were not implemented and were not personalized to the resident's needs. The DON acknowledged that the care plan was not applicable or individualized for this resident. Facility policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables, but this was not done in this case.