Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current care needs following an elopement. A facility-reported incident submitted to the State Survey Agency documented that resident #67 eloped from the facility without staff knowledge, exiting through an alarmed door that had been deactivated by a facility vendor. Staff interviews indicated that care plans were expected to be updated by nurses or designated staff after such events and on an as-needed basis. The facility’s incident investigation stated that the resident’s care plan was updated to reflect a need for closer monitoring and supervision when approaching facility exits. However, review of resident #67’s care plan entry dated 9/27/25 showed only that the resident was added to an elopement binder, educated not to leave the facility without assistance, and instructed to use an enclosed patio to enjoy the outdoors, along with general interventions such as engaging the resident in purposeful activity, identifying triggers for wandering or eloping, and providing calm, reassuring care. The care plan did not specify the need for closer supervision and monitoring when the resident approached facility exits, as identified in the incident investigation. This omission occurred despite a facility policy on elopements and wandering residents that required interventions to increase staff awareness of a resident’s risk and to minimize associated hazards to be added to the resident’s care plan and communicated to appropriate staff.
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