Failure to Address Resident Wandering in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, hypertension, muscle weakness, and cognitive communication deficit. Despite a history of wandering behavior, the resident's care plan did not address wandering until a significant increase in wandering was observed, at which point the resident was moved to memory care and the care plan was updated. Prior to this, the care plan lacked measurable objectives and timeframes to address the resident's wandering, even though staff and leadership were aware of the behavior. Interviews with the DON, Administrator, and staff confirmed that the resident had a longstanding pattern of wandering within the facility, which had recently escalated to include entering other areas such as resident rooms and administrative offices. The omission of wandering from the care plan meant that staff may not have been fully informed of the resident's behaviors or the best interventions to use. Facility policy required that assessment information be used to develop and revise comprehensive care plans, but this was not followed in the case of this resident until the behavior became more pronounced.