Failure to Develop and Revise Care Plan for Elopement Risk and Escalating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions and revise the care plan after a resident was identified as an elopement risk and exhibited escalating behavioral issues. The resident was cognitively intact, required assistance with transfers and ambulation, and had multiple diagnoses including coronary artery disease, hypertension, diabetes mellitus, CVA, malnutrition, generalized weakness, and a history of falls. The resident’s medication regimen included antiplatelet agents, hypoglycemics including insulin, and anticoagulant therapy. The care plan initially addressed areas such as impaired skin integrity risk, ADL decline, adverse medication reactions, fall risk, oral/dental issues, nutritional concerns, and discharge planning, but did not include a problem or interventions for wandering or elopement risk. Events leading to the deficiency included multiple behavioral incidents and a documented elopement-related event. On one date, the resident was involved in a verbal altercation in which another resident ran toward and punched him; no visible injuries were noted, and notifications were made. The following day, after a room transfer, the resident was involved in another verbal altercation with a new roommate and was then moved to a different nursing unit. Later, the resident went to the ER and left without being seen, returning to the facility on the same morning. Following this, an elopement risk evaluation identified the resident as at risk for elopement, with a score above the facility’s threshold for elopement risk, based on a history of attempting to leave without informing staff, wandering behavior, and recent admission with incomplete adjustment to the facility. Despite the new elopement assessment and ongoing behavioral concerns, the care plan was not updated to include elopement or wandering. Subsequent nursing documentation noted that the resident was found smoking in his room and verbally threatened another resident, and later remained on a Leave of Absence with unsuccessful follow-up phone contact. Behavioral concerns and smoking-related behaviors were added to the care plan after an incident in which the resident punched another resident, and a self-determination focus was added regarding the resident’s choice not to follow smoking rules. However, there was still no care plan developed for wandering or elopement risk. The social worker later reported being unaware that the resident had been identified as an elopement risk and not knowing that the care plan had been updated to reflect that status, confirming the lack of care plan revision specific to elopement risk.
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.