Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of dementia, behavioral disturbances, and high elopement risk. Despite the resident's documented severe cognitive impairment and previous elopement incidents, the care plan was not updated to address new elopement events. The care plan in place focused on general wandering and safety within the secured unit but did not include specific, measurable objectives or interventions following the resident's actual elopements. There was also no incident or accident report completed for a documented elopement, and the care plan was not revised to reflect this significant event. Interviews with facility staff, including the Administrator, DON, Regional RN Consultant, and MDS Coordinator, revealed a lack of awareness and follow-through regarding the need to update the care plan after elopement incidents. The MDS Coordinator acknowledged that care plans should be updated after such events but did not do so, believing the existing at-risk care plan was sufficient. The facility's policy required care plans to be revised after significant changes in a resident's condition, but this was not followed in the case of the resident's elopement.