Failure to Revise Care Plan After Elopement Incident
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include measurable interventions addressing an identified elopement risk. After an initial elopement incident, the facility's investigation summary specified that the resident should be monitored every 30 minutes for three days and placed on one-to-one supervision at night. However, these interventions were not incorporated into the resident's care plan, nor were they implemented. The care plan remained unchanged despite the resident's ongoing risk factors, including severely impaired cognition, wandering behaviors, and diagnoses such as adjustment disorder, dementia with mood disturbance and agitation, and Parkinson's disease. As a result of the care plan not being updated, the staff did not receive directives to implement the required interventions. Subsequently, the resident eloped again and was found by local police wandering on a nearby street, after which the resident was brought to the emergency room for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the care plan should have been revised to reflect the new interventions following the initial elopement, and that the failure to do so led to the deficiency.