F0656

J

Failure to Revise and Implement Comprehensive Elopement Care Plan for High-Risk Resident

Lawton, Oklahoma Survey Completed on 01-22-2026

Penalty

Fine: $17,630

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive care plan with measurable objectives and time frames to address a resident’s high elopement risk and repeated exit-seeking behaviors. The resident had severely impaired cognition with a BIMS score of 2 and diagnoses including dementia and anxiety. An admission assessment documented wandering behaviors and independent ambulation and transfers. Multiple Elopement Risk Assessments consistently identified the resident as high risk for elopement with scores of 10. Despite this, the care plan initiated for elopement did not show that interventions were revised or expanded after multiple elopement events and exit-seeking incidents.

The resident’s care plan, initiated in early May, included interventions such as distraction with food and activities, identifying patterns of wandering, and providing structured activities like signs, memory boxes, and walking inside and outside. These interventions were later cancelled in early August, and the care plan did not reflect additional or modified interventions after an elopement on mid-July. Incident reports documented that the resident eloped or attempted to elope on multiple occasions, including exiting with visitors, attempting to exit when a visitor or delivery driver held the door, and being found walking in the parking lot near a busy street and a storage facility. Each incident report stated that the resident was redirected inside, assessed, and that the care plan was updated to reflect current status, but the care plan did not show the addition of one-on-one supervision or other enhanced interventions corresponding to these events.

Facility documents titled "Resident One on One" showed that after each elopement or exit-seeking incident on multiple dates in July, August, and September, the resident was placed on one-on-one supervision for extended periods, ranging from several hours to most of a shift. However, one-on-one supervision was never added as an intervention in the resident’s care plan. A revised care plan in mid-October again focused on elopement and referenced the resident pulling on locked doors and walking out of the facility following visitors, but it only listed interventions such as distraction with pleasant diversions, observing for fatigue and weight loss, observing location in the community, and providing directional cues. It did not include prior elopements or the repeated use of one-on-one supervision as an intervention, nor did it show that interventions were revised after the multiple documented elopements and exit-seeking behaviors.

Staff interviews further illustrated the deficiency in implementing and communicating a comprehensive care plan. A CNA stated that interventions for elopement risk should be found in the care plan and reported being unsure what to do when a resident had multiple elopement attempts, indicating reliance on the RN for direction. Another CNA reported identifying residents at risk for elopement by word of mouth or the care plan and mentioned an elopement book but was unsure who checked it, also noting the difficulty of monitoring exits without constant presence at the door. The ADON stated that residents with an elopement risk score of 10 or higher were considered high risk and acknowledged that the resident’s care plan was revised after an early elopement attempt, but subsequent incidents still occurred. The DON stated that the resident eloped and was found in the parking lot near a very busy street and identified a system failure related to one-on-one forms and the lack of documentation in the care plan for the resident’s exit-seeking and elopements. A resident representative reported they were never informed that the resident was placed on one-on-one supervision and that the resident was later moved to another facility with memory care because the resident was not safe due to exit-seeking behaviors.

An Immediate Jeopardy situation was determined to exist related to the facility’s failure to ensure a comprehensive care plan was developed and implemented for this resident to prevent elopement. The facility’s own policy on comprehensive care plans required measurable objectives and time frames to meet resident needs identified in the assessment, with alternative interventions documented as needed. Despite repeated high-risk assessments, multiple elopements and exit-seeking incidents, and the repeated use of one-on-one supervision in practice, the resident’s care plan did not reflect these interventions or show appropriate revision after each incident. This failure to integrate actual interventions and incident history into the written care plan, and to ensure staff understood and followed it, formed the basis of the cited deficiency.

Removal Plan

• Elopement Risk Assessments were completed on 100% of residents.
• Facility completed 100% audit of residents who were identified at risk for elopement.
• Facility developed and implemented care plans to address elopements for all residents identified as at risk for elopement.
• IDT received education on reviewing, revising, developing and implementing care plans from the VP of Reimbursement or designee(s).
• IDT team implemented an appropriate monitoring sheet for residents at risk for elopement.