Failure to Implement Care Plan Intervention for Wandering Behavior
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as an elopement risk. The resident, who had diagnoses including schizophrenia, type 2 diabetes mellitus, and anemia, was noted to have fluctuating capacity for decision-making and moderately impaired cognitive skills, requiring supervision for daily activities. Although the care plan specified that wandering behavior should be documented and diversional interventions attempted, staff did not monitor or document any episodes of wandering, as they believed the resident had not exhibited such behavior. This lack of documentation and monitoring occurred despite the care plan's directive and the resident's identified risk factors. Interviews with facility staff, including a registered nurse and the assistant director of nursing, confirmed that the intervention to document wandering behavior was not followed. The staff acknowledged the importance of documenting such behaviors to prevent incidents and ensure continuity of care. The facility's policy required comprehensive, person-centered care planning, but there was no evidence that the specified intervention was implemented, resulting in the resident leaving the facility unnoticed.