Failure to Timely Develop and Document Elopement Risk Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to timely develop and implement a comprehensive care plan addressing elopement risk for a resident with dementia, cerebral infarction, and cervical spondylosis. The resident was assessed as an elopement risk and had a wander guard device applied, but the elopement care plan was not initiated until two days later. Additionally, the Certified Nurse Aide Assignment/Accountability Record and related monitoring instructions were not updated at the time the wander guard was placed, contrary to facility policy. Interviews revealed that staff relied on informal knowledge rather than documented instructions to monitor the resident's wander guard, and the required documentation in the care plan and CNA records was missing until after the delay was identified. The Director of Nursing confirmed that the care plan should have been updated immediately upon assessment and intervention, and that the omission was not in line with facility expectations or policy.