Failure to Timely Review and Revise Care Plans for Residents with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two of three sampled residents who exhibited exit-seeking and wandering behaviors. Both residents had cognitive impairments, including dementia and Alzheimer's disease, and were admitted with risk factors for wandering. Despite documented incidents of exit-seeking, attempts to leave, and actual elopement, the care plans for these residents were not updated in a timely manner to reflect necessary interventions for elopement prevention. For one resident, multiple nursing notes documented exit-seeking behaviors, including searching for keys, attempting to leave, and being found outside the facility after elopement, which resulted in a fall and injury. Although hourly location checks were initiated for a short period, these interventions were not documented in the care plan, and no interventions to prevent elopement were added until after the resident had already eloped and sustained an injury. The resident's care plan was not updated to include a wander guard or other preventive measures until after the incident occurred. The second resident, who also had severe cognitive impairment and a moderate risk for wandering, exhibited similar exit-seeking behaviors on multiple occasions. However, this resident was not reassessed for wandering or elopement risk after these incidents, and the care plan did not include a focus on elopement prevention until much later. Staff interviews confirmed that interventions such as redirection and hourly checks were used inconsistently and were not reflected in the care plans. The DON and administrator acknowledged that the residents were not reassessed or care planned for elopement risk in accordance with facility policy, and that interventions were not implemented or documented in a timely manner.