Failure to Revise Elopement Risk Care Plan After Resident Found Unattended Outside
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident identified as being at risk for elopement after an incident in which the resident was found sitting outside the building unattended. The resident had a history of dementia, tremors, dizziness, and hypertension, and was unable to complete a mental status interview, indicating significant cognitive impairment. Despite being found outside the facility by staff, the care plan, which had previously identified the resident as an elopement risk, was not updated to reflect this event or to add new interventions to address the change in the resident's condition. Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that the care plan was not revised following the incident, contrary to facility policy and expectations. The policy required care plans to be updated after any assessment or change in condition, and to accurately reflect current interventions and their effectiveness. The failure to update the care plan after the resident was found outside placed the resident at continued risk, as the care plan did not reflect the most current information or interventions needed to ensure safety.