Failure to Include Elopement Risk in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a resident within 48 hours of admission. Specifically, the baseline care plan did not address the resident's identified risk for elopement, despite an admission elopement risk assessment indicating the resident was at risk and required routine monitoring. The baseline care plan incorrectly stated that the resident did not have a history of wandering or elopement and omitted interventions related to elopement risk, even though the assessment and provider investigation report confirmed the risk and subsequent elopement event. Interviews with nursing staff, the ADON, DON, and administrator revealed that care plans are expected to include critical information such as fall and elopement risks, along with appropriate interventions. Staff relied on care plans and 24-hour reports for guidance on resident care, and it was confirmed that the ADON was responsible for updating care plans with new interventions. The facility's policy required comprehensive, person-centered care plans reflecting current assessments and interventions, but this was not followed in the case of the resident who later eloped from the facility.