Failure to Update Care Plan After Resident Elopement
Penalty
Summary
Staff failed to update the care plan for a resident who eloped from the facility, despite facility policy requiring nursing staff to revise the care plan after such an event. The resident, who had a history of dementia, impaired decision making, depression, and repeated attempts to exit the facility, was found to be at increased risk for wandering. The care plan had last been updated prior to the elopement and did not reflect the new exit-seeking behavior following the incident. On the night of the elopement, the resident left the facility without a walker and was found outside 25 minutes later without the wander guard bracelet, which is intended to alert staff when a resident approaches an exit. Nursing staff, including the RN on duty, acknowledged that the wander guard had not been checked as ordered, and the DON confirmed that no new interventions were added to the care plan after the incident. The MDS Coordinator also stated that the care plan was not updated as required, and that the charge nurse on duty was responsible for this task.