Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting interventions for elopement risk. A review of the resident's records showed that she was a woman with multiple diagnoses, including dementia and severe cognitive impairment, as evidenced by a BIMS score of 3. The resident required extensive assistance with activities of daily living and was assessed as high risk for wandering, with an elopement risk assessment score of 14. Despite these findings, her care plan did not include any strategies or interventions related to elopement risk. Further documentation revealed that the resident had expressed a desire to leave the facility and was observed gathering her belongings, indicating potential elopement behavior. Interviews with facility staff confirmed that the care plan lacked elopement interventions, and the facility's own policy required such risks to be addressed in the care plan. The Director of Nursing was unavailable for comment, and the MDS Coordinator acknowledged the omission. This failure to update the care plan could result in the resident not receiving necessary care and services to address her elopement risk.