Failure to Develop Baseline Care Plan with Elopement Interventions
Penalty
Summary
Facility staff failed to develop a person-centered baseline care plan with specific interventions for monitoring a resident identified as an elopement risk. The resident, who had dementia and a history of wandering and elopement attempts at home, was admitted to the facility and assessed as a wanderer. Although the baseline care plan noted the resident's wandering behavior, it did not include any interventions or instructions for staff to monitor the resident, despite the known risk. A few days after admission, the resident was found outside the building by housekeeping staff and was noted to be very confused at the time. Interviews with MDS coordinators confirmed that the baseline care plan did not contain monitoring interventions because the resident was on a locked unit. However, the resident was still able to leave the facility unsupervised, demonstrating that the lack of specific monitoring interventions contributed to the incident.