Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.