Failure to Implement Elopement Risk Interventions for Multiple Residents
Penalty
Summary
The facility failed to implement care plan interventions for three residents identified as being at risk for elopement. Each resident had a care plan intervention that included participation in a walker's club and the posting of their pictures at the first floor, second floor, and reception area to alert staff of their elopement risk. Despite these interventions being documented in the care plans, interviews and observations revealed that the interventions were not carried out. Staff members, including the Activities Director, LPNs, and the Receptionist, were either unaware of the location of the residents' pictures or confirmed that the pictures were not present at the designated areas. Additionally, the Director of Nursing confirmed that the walker's club was not being conducted as indicated in the care plans and that the pictures were not posted as required. The residents involved had significant cognitive impairments and medical conditions such as convulsions, cerebral infarction, hypertension, anxiety disorder, depression, diabetes, and epilepsy, which increased their risk for elopement. The care plans were not updated to reflect the lack of implementation of these interventions, and staff communication regarding the identification of wandering residents was informal rather than following the documented interventions. The failure to implement and update the care plan interventions was confirmed through staff interviews and review of facility documentation.