Failure to Update Care Plan for New Wandering Behavior
Penalty
Summary
The facility failed to update the care plan for a resident who developed new wandering behaviors. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and depression, and was assessed as having severe cognitive impairment and lacking decision-making capacity, was observed wandering within and outside the facility. Despite being found outside the facility and displaying behaviors such as taking items from snack carts and other residents' belongings, the care plan was not revised to address these new behaviors. Multiple staff interviews confirmed that the resident was known to wander and could become aggressive if not given desired items. On one occasion, the resident entered another resident's room and took personal belongings, which led to a physical altercation. The facility's own policies require care plans to be updated when there is a change in a resident's condition or behavior, and to address safety risks such as unsafe wandering. However, after the incident of the resident being found outside, there was no documented update to the care plan to address the wandering behavior, as confirmed by the Assistant Director of Nursing and review of the medical record.