Failure to Develop and Implement Comprehensive Elopement Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents identified as being at risk for elopement. One resident with dementia, depression, and anxiety was assessed as at risk for elopement due to cognitive impairment and independent wheelchair use, and had demonstrated exit-seeking behaviors, including attempting to leave the facility and making statements about going home. Despite these behaviors, the resident's care plan only included a Wander Guard device and did not provide individualized interventions or address the resident's specific exit-seeking actions. The care plan was not reviewed or revised after the resident exhibited further exit-seeking behavior, and staff did not increase supervision or implement additional interventions when the resident attempted to leave with belongings. Another resident with hemiplegia, cognitive deficits, and anxiety was also identified as at risk for elopement, but their care plan only addressed fall risk and included a Wander Guard on the wheelchair handle, without a focus area or individualized interventions for elopement or exit-seeking behavior. Staff interviews revealed that interventions for exit-seeking behaviors were being performed but not documented in the care plans, and there was confusion among staff about where such interventions should be recorded. The facility's policy required comprehensive assessments and care plans for residents at risk of elopement, but these were not fully implemented for the residents reviewed.