Failure to Revise and Implement Elopement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to revise and implement care plan interventions for a resident with dementia who was at risk for elopement and exhibiting consistent exit-seeking behavior. The resident had diagnoses of cerebral infarction and unspecified dementia with behavioral disturbances, and an annual MDS identified moderate cognitive impairment with daily use of a wander/elopement alarm. A care plan dated 11/13/25 documented impaired thought processes, potential wandering, and exit seeking, with interventions such as cueing, reorientation, supervision, maintaining a consistent routine and caregivers, and use of a wander guard on the wheelchair. However, the care plan section related to elopement and safety lacked evidence of interventions directed to this risk. A subsequent care plan dated 1/11/26 identified the resident as an elopement risk due to prior attempts to leave unattended, impaired safety awareness, dementia, and memory impairment, and included general distraction interventions (activities, food, conversation, television, books), but no additional interventions were added despite a significant history of wandering and packing a suitcase with the intention of going home. The resident’s Wandering Risk Scale dated 10/23/25 documented a recent history of packing items in a suitcase intending to go home and being difficult to redirect, with a wander guard in place on the wheelchair. Progress notes showed that on 1/11/26 the resident became agitated, expressed a desire to go home, packed belongings, opened a door, and stepped outside into the snow before staff redirected the resident back inside; the wander guard had been changed the day before and was reported as functioning normally, but did not activate at the door. The medical record lacked evidence that care-planned interventions such as redirection, reorientation, or increased supervision were implemented prior to this elopement event, despite clear signs of elopement behavior. During interviews, the MDS RN and social worker reported that the IDT met after the elopement and reviewed the care plan, initially determining no changes were needed; upon review, the MDS RN acknowledged the care plan was not complete and should have included more specific interventions, and the social worker acknowledged not having recently worked with the family to develop a more personalized care plan, despite the resident being an avid reader and a hoarder with limited books in the room.
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