Failure to Develop and Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the elopement risk for a resident who was assessed as high risk for elopement upon admission. Despite the resident's medical history, which included dementia, cognitive communication deficit, difficulty walking, and other significant diagnoses, and a documented high risk for elopement on an evaluation, there was no care plan in place to address this risk. On one occasion, the resident was able to leave the activity patio area through a side gate without staff awareness and was found outside the building by a visitor, who then notified staff. The resident was redirected back into the facility by staff after being found outside. Interviews with facility staff, including the Unit Manager and DON, revealed that they did not consider the incident to be an elopement and therefore did not implement or update an elopement risk care plan for the resident after the event. Review of the resident's comprehensive care plan confirmed there was no documentation of interventions or updates following the incident to address the resident's wandering behavior and elopement risk, despite facility policies requiring such actions for residents identified as at risk.