Failure to Revise Elopement Care Plan After Multiple Incidents
Penalty
Summary
The facility failed to update and revise the care plan for elopement for one resident after multiple elopement incidents, despite regulatory requirements that care plans be developed, reviewed, and revised by a team of health professionals. Record review showed the resident’s elopement care plan, initiated on 09/28/25, identified a concern for elopement but contained no evidence of review or updates following elopement events on 10/15/25, 11/06/25, 01/16/26, 02/08/26, or 02/09/26. On 02/19/26, an LPN confirmed that the elopement interventions had not been updated since the care plan was first developed. On 02/23/26, another LPN reported believing that the DON had recently updated the elopement care plan, which was not the case. Later that same day, the DON stated that the care plan for this resident had not been updated because the interim MDS nurse had not performed their duties. These findings demonstrate that, although the resident had repeated elopement episodes documented in the record, the care plan remained unchanged from its original version, and staff interviews confirmed that no revisions were made in response to the subsequent events.
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.