Failure to Reassess and Care Plan After Resident Leaves Facility Unsupervised
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes with foot ulcer, peripheral vascular disease, anxiety disorder, and paraplegia, who had moderately impaired cognition, was able to leave the facility premises without staff knowledge or supervision. The resident, who required total assistance from two staff members for dressing, transferring, and repositioning, asked another resident to push their wheelchair to a store. Facility staff intervened and returned both residents to the facility. At the time of the incident, the resident's admission elopement risk assessment indicated no risk for elopement, and there was no activated power of attorney. Following the incident, the facility did not reassess the resident for elopement risk, did not evaluate the resident's ability to leave the facility unsupervised, and did not initiate or update the care plan to address the risk of the resident leaving the facility or seeking assistance from peers to do so. The facility's policy requires a systemic approach to monitoring and managing residents at risk for elopement, including assessment, care planning, and intervention, but these steps were not taken after the event. Additionally, there were no care plan interventions related to the resident's potential alcohol-seeking behaviors, which was a concern raised by staff.