Failure to Update Care Plan After Resident Elopements
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect each incident of elopement. A resident with severe cognitive impairment, including diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and psychotic disorder, was identified as being at risk for elopement. Despite multiple documented incidents where the resident left the facility unsupervised, the care plan was not updated after each event. The initial care plan addressing elopement risk was not created until two days after the first documented elopement, and subsequent elopements were not reflected in the care plan at all. Record review and staff interviews confirmed that the care plan did not document the actual elopement events, nor was it revised following additional incidents. The facility's policy required the interdisciplinary team to review and update the comprehensive care plan after each assessment, but this was not followed in practice. Staff responsible for updating care plans were either unavailable or assumed updates had been made, and the Director of Nursing confirmed that no updates were found in the care plan after the resident's repeated elopements.