Failure to Develop Person-Centered Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with cognitive impairment and a history of elopement. The resident, admitted with diagnoses including senile degeneration of the brain, diabetes mellitus type II, and anxiety, was found walking in the parking lot toward the street. Following this incident, the resident was admitted to the secure memory care unit. However, the care plan created did not include person-centered interventions or reflect the resident's transfer to the secured unit. Review of the care plan showed only generic interventions such as administering medications as ordered and anticipating the resident's needs, without addressing the unique factors contributing to the resident's elopement risk. The Director of Nursing confirmed that the care plan lacked a person-centered approach. Facility policies require comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not evident in the resident's documentation.