Failure to Care Plan for Identified Elopement Risks
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing elopement risk for four residents identified as being at risk. For one male resident with dementia, adjustment disorder, alcohol abuse, and psychosis, the care plan noted that he wanted to go across the street to visit a friend and that he had previously left the facility without notifying staff to go to a corner store. The care plan included reminders about safety concerns and a psychiatric review for anxiety and agitation related to missing his friend, but there was no care planning addressing his ongoing elopement risk despite multiple Elopement Risk Assessments scoring him as an elopement risk. His record also showed a documented elopement incident, and during observation and interview he was unable to recall the incident or state the facility’s procedure for leaving, indicating he would simply walk out the front door and was unsure if he should tell staff. Another female resident with a diagnosis of psychotic disorder with delusions had an annual MDS showing severely impaired cognition and no documented wandering behavior, but her most recent Elopement Risk Assessment scored her as an elopement risk. Her care plan did not contain any interventions or planning related to elopement risk. During observation, she was seen interacting with staff in a common area but was unable to participate meaningfully in an interview due to her mental status and did not answer interview questions, instead focusing on her personal history. A male resident with herpesviral encephalitis had an admission MDS indicating intact cognition and no wandering behavior, but his Elopement Risk Assessment score also indicated elopement risk, with no corresponding elopement-related care planning in his care plan. He was observed alone in an unoccupied wing inspecting a handrail, with no staff present, and reported he had never attempted to leave the facility before ending the interview. Another male resident with dementia had an annual MDS showing severely impaired cognition and daily wandering behavior, and his most recent Elopement Risk Assessment also indicated elopement risk, yet his care plan contained no elopement-related planning. He was observed sleeping in bed and declined to participate in an interview. Facility leadership, including the RCN and ADO, reported that there had been a leadership change, that the DON was new and had not yet reviewed all care plans, and that Elopement Risk Assessments were intended to alert the IDT so that risks and interventions, including possible secured unit placement, could be determined and incorporated into care plans. The facility’s comprehensive care planning policy stated that risks identified in the MDS or otherwise should be assessed and considered for care plan development, but this was not done for the four residents’ elopement risks.
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