Failure to Develop Baseline Care Plan for High-Risk Wandering Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was identified as high risk for wandering and elopement. Despite the resident's documented history of psychiatric conditions, including bipolar disorder, psychosis, major depressive disorder, and a history of increased agitation and auditory hallucinations, no care plan was created to address the resident's high risk of wandering. The resident's clinical record and assessments indicated a high risk for wandering, but this was not reflected in a care plan with specific interventions. On the day of the incident, the resident was escorted by a CNA to an outpatient appointment but was lost during the outing. Staff interviews revealed that while the resident was considered alert and ambulatory, there was an expectation that staff would closely monitor residents, especially those at high risk. However, the lack of a care plan meant there were no documented interventions or instructions for staff to follow, which contributed to the resident's successful elopement from the facility. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident in question.