Failure to Develop and Implement Care Plans for Elopement and Smoking
Penalty
Summary
The facility failed to develop and implement appropriate care plans for two residents, resulting in deficiencies related to elopement and smoking safety. One resident with diagnoses including myopathy and dementia, and a documented history of attempted elopement, was admitted without a care plan addressing elopement risk. Despite hospital discharge paperwork noting a prior elopement attempt and nursing notes describing behaviors such as attempting to leave the facility and refusing to return inside after going out to smoke, the resident's care plan did not include interventions for elopement. The facility's own policy required assessment and prevention strategies for residents at risk of elopement, but these were not followed for this resident. Another resident, admitted with chronic obstructive pulmonary disease and dysphagia, and who was cognitively intact, was known to be a smoker and participated in supervised smoking times. However, a care plan addressing smoking safety was not developed until approximately two months after admission, contrary to the facility's policy that required immediate assessment and documentation of smoking safety needs in the care plan. Both deficiencies were confirmed through record review and staff interviews, which acknowledged that care plans for elopement and smoking should have been implemented upon admission.