Failure to Develop Comprehensive Care Plan for Resident with Wandering History
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing all of a resident's needs, specifically regarding wandering and elopement risk. One resident was admitted with a documented history of dementia, muscle weakness, generalized anxiety disorder, and prior incidents of wandering and aggression as reported by family and hospital records. Despite this history, the facility did not initiate a care plan for wandering or elopement risk. The resident's care plans focused on impaired cognition and forgetfulness/confusion, with interventions such as maintaining a consistent routine and providing reminders for activities, but did not address the risk of wandering or elopement. The Director of Nursing stated that the assessment on admission did not reveal wandering or exit-seeking behaviors, and that the hospital documentation reviewed did not indicate wandering, which led to the omission of a wandering or elopement care plan. However, the hospital records and family reports did document a history of wandering prior to admission. As a result, the facility did not meet the regulatory requirement to develop a comprehensive care plan that includes measurable objectives and timetables to address all identified needs, including the risk of wandering and elopement.