Failure to Update Care Plan and Supervision After Resident Elopement
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 7 out of 15 and diagnoses including anxiety disorder, depression, and non-Alzheimer's dementia, was admitted to the facility. The resident was able to leave the facility unattended, as observed by the Admissions Director, who saw the resident exiting the building with visitors and subsequently entering a nearby business. Staff were alerted via two-way radio, and a registered nurse located the resident at the business and accompanied him. The resident's wander guard device did not alarm at the facility entrance, which was the point of exit. Following the elopement, there was no evidence that the resident's care plan was updated with new interventions to address the incident, despite facility policy requiring such updates after an elopement. Multiple staff interviews confirmed that no new interventions were added to the care plan after the event. The facility's policy on elopement, which includes updating the care plan and interventions after a resident is located, was not followed in this instance.