Failure to Update Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to assess and update the care plan with appropriate interventions for wandering for one resident. Despite the resident having a history of dementia, low vision, and hearing impairment, and being observed wandering the halls, entering other residents' rooms, and displaying combative behavior, the care plan was not adequately revised to address these behaviors. Staff interviews revealed that there was no formal assessment of the resident's behaviors, and interventions were inconsistently applied, such as offering a drink or taking the resident outside, without clear documentation or individualized planning. The resident's electronic health record showed a low risk of wandering based on an outdated assessment, despite frequent documented incidents of wandering and intruding on others' privacy. The care plan listed the resident as an elopement risk/wanderer but lacked specific, individualized interventions and did not specify de-escalation strategies. Facility policy required that residents identified as at risk for wandering have care plans with strategies and interventions to maintain safety, which was not followed in this case.