Failure to Update Care Plan After Repeated Elopement Attempts
Penalty
Summary
The facility failed to update and revise the care plan for a resident who made repeated attempts to elope from the facility on two separate occasions. According to the facility's own care planning policy, staff are required to use assessment data to develop and update a comprehensive plan of care that addresses each resident's needs. Despite documentation in the nursing progress notes that the resident left the building through the front door and, on a later date, exited into the parking lot and down the street while becoming combative, no new interventions were added to the resident's care plan after these incidents. The resident's care plan, last revised prior to the elopement attempts, already identified the individual as an elopement risk and included interventions such as distraction, monitoring for fatigue and weight loss, and redirection. However, after the documented elopement events, the care plan was not reviewed or updated to include additional measures. This was confirmed by the Care Plan Coordinator, who acknowledged that the management team did not revise the plan following the resident's recent attempts to leave the facility unattended.