Failure to Timely Develop Care Plans for Wandering and Elopement Risks
Penalty
Summary
The facility failed to develop and implement timely, individualized care plans for two residents with identified behavioral and safety risks. For one resident with severe cognitive impairment, documentation showed the resident exhibited wandering behavior by attempting to enter other female rooms, as noted on an assessment dated 8/13/25. Despite this, there was no evidence that a care plan addressing this behavior was developed prior to the resident's elopement on 8/17/25. Both the RN and DON confirmed that the care plan should have been initiated as soon as the wandering behavior was observed, but it was not started until after the elopement occurred. For a second resident with moderate cognitive impairment, an assessment identified the resident as being at risk for elopement. However, the medical record did not show that a care plan addressing this risk was developed until several days after the risk was identified. The RN and DON both acknowledged that the care plan should have been created immediately upon identification of the elopement risk. These failures were confirmed through interviews and medical record reviews, and were acknowledged by facility leadership.