Failure to Develop Comprehensive Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address the needs of a resident with a history of homelessness, anxiety disorder, and psychoactive substance abuse. The resident was admitted with these diagnoses and was later identified as being at risk for elopement based on an assessment conducted after admission. Despite this identified risk, the resident's care plan did not include specific interventions to prevent elopement, nor did it address the need for adequate staff oversight at the facility's main entrance, where the resident was frequently observed. On the day of the incident, the resident, who was nonverbal, wheelchair-bound, and exhibited exit-seeking behavior, was able to leave the facility through the main entrance. This occurred when a visitor held the door open, allowing the resident to exit in her wheelchair. The resident was found outside by a staff member and returned to the facility. Documentation and interviews confirmed that the care plan lacked necessary interventions based on the resident's elopement risk and the facility's traffic patterns at the main entrance.