Failure to Individualize Care Plans for High-Risk Wandering Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for wandering or elopement had person-centered care plans individualized to their specific needs. Eight residents with diagnoses such as dementia, depression, heart failure, and Alzheimer's disease were identified as having behaviors or histories that placed them at risk for wandering or elopement. Each of these residents had completed elopement evaluations indicating risk factors such as aimless wandering, history of elopement attempts, and verbal expressions of wanting to leave the facility. Despite these individualized risk factors, a review of the care plans for all eight residents revealed that the plans were nearly identical, lacking specific interventions or goals tailored to each resident's unique needs and behaviors. The care plans included generic goals such as maintaining resident safety, ensuring happiness with daily routines, and preventing residents from leaving the facility unattended. Interventions listed were also generic, including assessing for fall risk, providing diversions, monitoring for fatigue, and offering structured activities, without any customization based on the resident's personal history or preferences. The facility's own policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as ongoing assessment and revision as resident conditions changed. However, interviews and documentation confirmed that the facility did not meet these requirements for the eight residents at high risk for wandering or elopement, resulting in a deficiency under state regulations for admissions policy and nursing services.