Failure to Develop Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement a care plan addressing exit-seeking behaviors for a resident with moderate cognitive impairment and a diagnosis of dementia. Despite documentation indicating the resident was at risk for elopement and the use of a security bracelet/elopement alarm, there was no evidence that a care plan with measurable objectives and timeframes was created when the risk was first identified or when the security device was initiated. Staff interviews confirmed the resident frequently asked for keys and ways to leave the facility, and that the risk for elopement was known among nursing staff. Record reviews and staff interviews further revealed that the care plan process policy required individualized care plans to address residents' unique needs and to be updated as necessary. However, the resident's care plan did not include interventions or goals related to elopement risk until the day of the surveyor's inquiry, despite the risk being documented months earlier. The Director of Nursing confirmed that the care plan should have been developed when the risk was initially identified, but this was not done until prompted by the survey.