Failure to Assess, Document, and Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who experienced an elopement event. After the resident, who had multiple diagnoses including diabetes type I, epilepsy, Parkinson's disease, and a history of central nervous system infection, left the facility without staff knowledge, the facility did not complete a new wander risk assessment to address the change in the resident's condition. The resident was found by an LPN outside the facility, exhibiting altered mental status, and was subsequently transported to the hospital for evaluation. Following the elopement, the facility applied a wanderguard bracelet to the resident; however, there was no documentation of a physician's order for the use of the wanderguard or for monitoring its function. Additionally, the resident's care plan was not updated to reflect the use of the wanderguard or to address the increased risk for wandering or elopement after the incident. The electronic medical record did not contain an assessment for the use of the wanderguard prior to its implementation, nor did it include documentation related to the change of condition on the day of the elopement. Staff interviews confirmed that a physician's order should have been obtained for the wanderguard and that the care plan and risk assessment should have been updated following the event. The DON acknowledged the lack of these updates and documentation. The facility's own policy required identification of residents at risk for wandering and updating care plans with appropriate interventions, which was not followed in this case.