Failure to Implement and Update Care Plan Following Resident Elopement
Penalty
Summary
The facility failed to implement and update a comprehensive care plan for a resident with vascular dementia and a mood disorder, who had a moderately impaired cognitive status as indicated by a BIMS score of 12 out of 15. The resident was allowed to sit outside unescorted after expressing a desire to do so, and the nurse verbally agreed and intended to obtain a physician's order for an out on pass, but failed to document the order or update the care plan. The resident subsequently left the facility grounds unaccompanied, was found wandering on a multi-lane highway by a passerby, and was later brought to a police precinct where the resident experienced a syncopal episode and required transfer to the emergency room. Review of the resident's care plan revealed it included an intervention for community pass with escort only, but the plan was not updated following the incident or after the resident's quarterly MDS assessment. The facility's policies required care plans to be reviewed and updated after significant incidents and changes in condition, but this was not done. Staff interviews confirmed that the care plan was not revised post-incident, and the required physician's order for the out on pass was not documented, resulting in a lack of communication and appropriate interventions for the resident's safety.