Failure to Develop and Implement Person-Centered Elopement Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing elopement risk for a resident with significant cognitive impairment and behavioral health diagnoses, including autistic disorder, anxiety, traumatic brain injury, and dementia with agitation. Despite the resident's history and a low BIMS score indicating cognitive impairment, the care plan did not include specific or practicable interventions for de-escalating behaviors related to elopement. During an observed incident, the resident, wearing a wanderguard, attempted to leave the facility multiple times, triggering door alarms and escalating in agitation when staff attempted to intervene. Staff responses varied, with some attempting to physically redirect the resident and others seeking assistance, but only one staff member was aware of effective de-escalation techniques tailored to the resident's needs. Interviews confirmed that the staff assigned to supervise the resident were not informed of the appropriate interventions, which were only known to a single employee. The resident's care plan had not been updated to reflect these effective strategies, despite their demonstrated success in calming the resident during the incident. Facility policy required comprehensive, individualized care plans to be developed and revised after each assessment, but this was not followed, resulting in a lack of consistent, person-centered interventions for the resident's elopement risk and behavioral needs.