Failure to Revise Care Plan and Ensure Supervision After Resident Elopement
Penalty
Summary
The facility failed to revise care plan interventions and re-evaluate a resident's elopement risk, resulting in inadequate supervision and failure to prevent repeated elopements for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including psychosis, delusional disorder, schizophrenia, and suspected vascular dementia, was under guardianship and had documented impaired strength, balance, and endurance. Despite these factors, the care plan did not address the resident's elopement incidents, and no new interventions were developed after the resident left the facility on two occasions. Progress notes indicated the resident expressed a desire to leave, and staff allowed the resident to leave against medical advice (AMA), only leaving a voice message for the guardian rather than using the emergency contact as specified in the guardianship paperwork. Staff interviews revealed a lack of awareness regarding the resident's guardianship status and the appropriate procedures for contacting the guardian. Staff members believed the resident was alert and oriented and had the right to leave, despite documentation indicating the resident lacked decision-making capacity. The facility did not conduct investigations into either elopement incident, and staff failed to notify law enforcement or use the correct emergency contact methods. The guardian confirmed that she was not contacted appropriately and reiterated that the resident did not have the capacity to make decisions about leaving the facility.