Failure to Timely Revise Care Plan After Resident Elopement
Penalty
Summary
The facility failed to revise a comprehensive care plan and did not develop a care plan with measurable goals, objectives, and individualized interventions to address the need for increased supervision and preventive interventions for a resident at risk for elopement. The resident, who had diagnoses including schizophrenia, hyperlipidemia, cerebral infarction, bilateral primary osteoarthritis of the knee, dementia, and PTSD, was admitted with a history of expressing a desire to leave the facility and demonstrated cognitive decline as evidenced by a decrease in BIMS scores. Despite being identified as an elopement risk and placed on elopement protocol upon admission, the care plan was not updated in a timely manner following a significant incident. The resident eloped from the facility without staff knowledge, and the absence was only discovered after a family member notified the facility. The care plan addressing elopement risk was not revised until several days after the incident, and no new interventions were implemented until even later. Documentation and interviews confirmed that the care plan was not promptly updated after the elopement, and the facility's own policy required reassessment and care plan revision following such events. The lack of timely revision and individualized interventions contributed to the deficiency.