Failure to Develop and Implement Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited exit-seeking and wandering behaviors. Despite the resident being identified as having severe cognitive impairment and being assessed for wandering and elopement risk, there was no care plan addressing these behaviors or the use of a Wander Guard device. Documentation showed that the resident attempted to exit the facility, was evaluated for elopement risk, and had a Wander Guard applied, yet these interventions were not reflected in the resident's care plan. Facility policy required that residents with wandering or elopement risk receive adequate supervision and have their needs addressed in a person-centered care plan. Interviews with facility leadership confirmed that the omission of a care plan for wandering was an oversight, and that multiple staff were responsible for reviewing care plans. The lack of a care plan meant that staff did not have documented guidance on how to address the resident's wandering behaviors, contrary to facility policy and professional standards.