Failure to Monitor and Care Plan for Resident at Elopement Risk
Penalty
Summary
The facility failed to properly monitor a resident at risk for elopement, resulting in multiple incidents where the resident was found outside the building. The resident, admitted with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression, was identified as having a history of wandering and exit-seeking behavior. Despite an elopement risk assessment indicating the need for elopement risk protocol, there was no evidence that this risk was incorporated into the resident's comprehensive care plan. Additionally, there was no documentation of a completed admission Minimum Data Set (MDS) assessment or a wander risk assessment following the elopement incidents. Clinical records showed that after the resident was found outside the facility on two separate occasions, appropriate notifications to the provider and family were not documented. Staff interviews confirmed that the expected protocol for elopement risk, including care plan updates and timely notifications, was not followed. The facility's own policy required individualized care plans and timely assessments for residents at risk of elopement, but these measures were not implemented for this resident.