Failure to Develop and Implement Care Plan for Resident's Wandering Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's history of wandering. Record reviews showed that although the resident was listed as a wanderer on the facility's list, there was no corresponding focus, goal, or intervention for wandering in the resident's care plan. The resident had a severely impaired cognition as indicated by a BIMS score of 3, and was diagnosed with altered mental status and UTI. However, the clinical risk assessment and MDS did not code for wandering, and the care plan did not reflect this behavior. Interviews with the DON, MDS, and Administrator confirmed that the resident's wandering behavior should have been care planned, and that it was the responsibility of the MDS department to ensure care plans were accurate and complete. The lack of a care plan for wandering was acknowledged as an oversight, with staff stating that care plans are necessary to inform staff of resident needs and to provide appropriate care. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not followed in this case.