Failure to Implement Comprehensive Elopement Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as an elopement risk, resulting in two separate incidents where the resident exited the building unwitnessed. The resident wore a wander guard bracelet intended to trigger secured exits, and the care plan directed staff to redirect the resident from exits and, when the resident was upset and attempting to leave, to have staff sit with the resident. However, during both incidents, staff only redirected the resident multiple times and did not provide the one-on-one supervision as outlined in the care plan. On both occasions, the resident was able to leave the facility without being witnessed, despite staff being aware of the resident's repeated exit-seeking behaviors. Interviews with staff and the DON confirmed that no one sat with the resident during these episodes, and staff were unable to provide adequate supervision, particularly during times of limited staffing. The care plan interventions were not fully implemented, as staff did not follow the directive to have someone sit with the resident when exhibiting elopement behaviors.