Failure to Individualize Care Plans for Residents at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with severe cognitive impairment and a history of exit-seeking behaviors. For one male resident with dementia and a BIMS score indicating severe cognitive impairment, the care plan included generic interventions such as door alarms, quarterly elopement assessments, and offering distractions. However, the care plan did not address the resident's specific behaviors, such as his fixation on white cars and cigarettes, or his pattern of looking out windows and attempting to exit the building. Multiple staff interviews confirmed that the resident routinely checked doors, set off alarms, and expressed a desire to leave the facility for cigarettes or to return home, but these behaviors were not specifically documented or communicated in his care plan. On one occasion, this resident was able to leave the facility unsupervised and was found walking alone along a road by a staff member, who then returned him to the facility. Staff interviews revealed that while staff were aware of the resident's exit-seeking tendencies and specific interests, such as white cars and cigarettes, this information was not consistently documented or included in the care plan. The Director of Nursing and other staff acknowledged that care plans were not individualized and that there was no system in place to monitor or document escalating behaviors that could lead to elopement. A second female resident with dementia and severe cognitive impairment was also identified as an elopement risk, with a history of looking for family and attempting to leave the facility. Her care plan similarly relied on template interventions and did not include specific, individualized strategies to address her behaviors. Staff interviews indicated a lack of awareness and monitoring for elopement risk, and the care plan was not customized to reflect the resident's unique needs or patterns of behavior. The facility's practice of using pre-selected, non-individualized care plan templates contributed to the failure to adequately address and manage the elopement risks for both residents.