Failure to Individualize Elopement Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop a person-centered, individualized care plan to address an assessed elopement risk for one resident. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, leading to initiation of an elopement care plan. The Resident Care Plan documented that the resident was at risk for elopement related to dementia, with a history of wandering in the community and at the facility, and a past occupation as an elevator repair person who believed he had service calls and wanted to leave at night. Interventions listed were general in nature, such as introducing staff in a calm manner, explaining routines, orienting to room and environment, performing frequent checks, placing a picture in the business office, and encouraging family to bring familiar objects. The resident’s MDS showed moderately impaired cognition, independent ambulation of at least 150 feet, and wandering behaviors several days per week. Clinical documentation and interviews showed specific behaviors and circumstances that increased the resident’s elopement risk but were not reflected in individualized care plan interventions. Psychiatric notes over several months described late evening and early morning wakefulness, agitation, confusion, wandering, insomnia, and the resident looking for a family member at night, with PRN Trazodone ordered for agitation/insomnia. Staff interviews reported that the resident stayed up at night, wandered the hall, and packed belongings at night to go home. The resident’s room was located far from the nursing station and closest to an exterior fire door. An incident report documented that an exterior fire door alarm sounded during the night and the resident was found outside that door on hands and knees. Despite the facility’s written policy that residents identified as elopement risks would have a wander guard bracelet, photo ID placement, and periodic elopement drills, the care plan did not include individualized interventions addressing the resident’s nighttime wandering, confusion, searching for family, packing to leave, or room location near an exit, and the facility had not conducted or documented elopement drills.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.