Failure to Implement Elopement Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with a known history of elopement attempts. The resident, who had dementia and a moderate cognitive impairment as indicated by a BIMS score of 9, was identified as being at risk for wandering and elopement. The care plan required that a wander guard be placed on the resident every shift and that its placement and function be monitored. However, on the day of the incident, staff observed the resident without a wander guard, and multiple staff interviews confirmed that the device was not replaced when missing, despite facility protocol requiring immediate replacement. The resident was last seen in the facility hallway and was later found unsupervised outside the facility, approximately 0.2 miles away. Staff interviews revealed that the LVN noticed the missing wander guard but did not replace it, believing it was not her responsibility. The DON confirmed that the resident was not wearing the required wander guard when found outside. Facility policies required comprehensive assessment and implementation of resident-centered care plans to mitigate safety risks, but these were not followed in this instance, resulting in the resident eloping from the facility.