Failure to Update Care Plan After Elopement Attempt
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for a resident at risk for elopement after an elopement attempt was documented. The resident, who had diagnoses including dementia without behavioral disturbance, diabetes mellitus, generalized anxiety disorder, and encephalopathy, was admitted to the facility and was known to self-propel in a wheelchair. On one occasion, the resident eloped from the facility through the front door, triggering the alarm, and was subsequently returned to the facility. The nurse on duty redirected the resident throughout the night and reported the incident during shift change but did not notify the Director of Nursing (DON) or update the care plan to reflect the new behavior and risk. There was no documentation in the resident's care plan regarding the elopement attempt, activation of the front door alarms, or the need for physical assistance to return the resident to the facility. The DON and the Care Plan Coordinator were not made aware of the incident until weeks later, and the care plan was not revised with new interventions until after a subsequent elopement occurred. Staff interviews confirmed that the resident had been actively exit-seeking, particularly during evening and night hours, and required frequent redirection. The resident exhibited increased confusion and fixation on leaving the facility for a specific purpose, which was a recent behavioral change. Facility policy required that any new onset or change in behavior, especially those increasing elopement risk, be documented and incorporated into the care plan with individualized safety interventions. Despite these policies, the care plan was not updated in a timely manner following the initial elopement attempt, and the required communication and documentation procedures were not followed. This lapse resulted in the resident's increased risk not being addressed promptly in the care plan.