Failure to Develop Comprehensive Care Plan for Wandering/Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan to address the risk of wandering and elopement for a resident. Although the resident had diagnoses including unspecified intracranial injury, hepatitis C, and liver cirrhosis, and was not initially assessed as being at risk for elopement, physician orders were in place for the use of a Wander Guard and for monitoring its placement and functionality. Despite these orders, the clinical record did not document any assessment or evidence of wandering or elopement behaviors that would justify the use of the Wander Guard, nor did it include a care plan outlining specific interventions, problem areas, causes, or measurable objectives related to wandering or elopement prevention. An incident occurred in which the resident was found outside the facility and was immediately brought back inside, after which a head-to-toe assessment revealed no injuries. Review of the resident's care plan showed that from the time the Wander Guard was ordered until after the incident, there was no documented plan of care addressing the use of the Wander Guard or interventions for wandering or elopement. Facility leadership confirmed that a comprehensive care plan with individualized interventions for wandering/elopement was not developed for this resident.