Failure to Care Plan for Resident at Risk for Wandering and Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing wandering and elopement risk for a resident who had been assessed as at risk. An MDS admission assessment dated 12/01/24 documented that the resident’s cognition was moderately impaired, and that the resident experienced delusions and wandered one to three days in the previous seven days. A quarterly wandering/elopement assessment completed by an LPN on 09/02/25 showed "yes" responses to questions about resistance to being placed in the facility, a history of wandering, confusion and disorientation, and indications of dementia. The assessment form’s instructions stated that a single "yes" answer required the resident to be placed on wandering/elopement precautions. A subsequent MDS admission assessment dated 12/04/25 showed the resident’s cognition had declined to severely impaired, with continued delusions and wandering one to three days in the previous seven days. Despite these findings, the resident’s care plan revised on 12/06/25 contained no problem, goals, or interventions related to wandering or elopement risk. During an interview on 12/18/25, the ADON, who stated they were responsible for creating resident care plans, reviewed the care plan and confirmed there were no entries addressing wandering or elopement. The ADON acknowledged that, given the resident’s dementia and wandering behavior, problems related to wandering and elopement should have been included in the care plan.
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