Failure to Follow Elopement Care Plan for Resident Lacking Capacity
Penalty
Summary
The facility failed to implement and follow the individualized care plan for a resident who lacked capacity to make medical decisions and had a history of mild, intermittent confusion. The resident's care plan, initiated due to elopement risk, specified that the resident was not to leave the facility without being accompanied by a responsible person. Despite this, the resident was allowed to leave the facility for an outpatient medical appointment without accompaniment from a responsible party or the resident's responsible person, as required by the care plan and physician orders. Medical records indicated that the resident left the facility under approved authorization for an appointment but did not return directly afterward, instead going to his apartment before eventually returning to the facility. Documentation did not show that the responsible party was informed or present, and the responsible party later confirmed she was not notified of the appointment or the need to accompany the resident. The DON verified that the care plan was not followed and that the responsible party was not informed, resulting in the resident leaving unaccompanied and eloping after the appointment.