Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan to include a critical elopement-safety intervention for a resident with a history of wandering and severe cognitive impairment due to traumatic brain injury. The resident was admitted with orders to reside in a locked unit and was identified as being at high risk for elopement, requiring 24/7 supervision. Despite these known risks and a previous elopement incident at another facility, the care plan did not reflect the need for 1:1 supervision when the resident was taken off the locked unit. On the day of the incident, the resident was taken outside with staff to see animals and subsequently went missing from the front parking lot. Elopement protocols were initiated, and the resident was returned by police without injury. Interviews with staff and leadership confirmed that the root cause of the elopement was inadequate supervision and that the care plan had not been updated to include the newly implemented intervention of 1:1 supervision when off the locked unit, despite this being recognized as necessary after the incident.