Failure to Develop Specific Elopement Care Plan and Accurately Monitor Exit-Seeking Behavior
Penalty
Summary
The deficiency involves the facility’s failure to provide quality care to a resident at risk for elopement by not developing specific and measurable care plan interventions and not accurately following physician orders for monitoring elopement attempts. Resident 1, admitted 29 days prior and diagnosed with respiratory failure, falls, and Alzheimer’s disease, had an elopement risk assessment score of 7, indicating a moderate elopement risk. The resident’s care plan identified risk for elopement and wandering due to a history of elopement/wandering and impaired cognitive function and safety perception, with an intervention to “check resident’s whereabouts,” but it did not specify how often or when staff should check on the resident. During an interview and record review, the DON acknowledged that the care plan intervention was not specific. The facility’s care plan policy required comprehensive, person-centered care plans with measurable objectives and timetables. The facility also failed to follow a physician order related to monitoring elopement attempts. The order summary included an order to monitor the number of times per shift the resident attempted exit-seeking behavior on every day shift, starting on 1/30/26. On 2/19/26, a grievance documented that a family member was informed by another resident that Resident 1 had left the building. Resident 2, who was cognitively intact per a BIMS score of 15, and CNA 1 both stated they saw Resident 1 open the conference room door and walk outside. However, review of the MAR for February showed that staff documented “0” exit-seeking attempts for that date, and the DON stated staff should have charted a “1” for the elopement attempt. The facility’s wandering and elopement policy stated that residents identified as at risk for wandering or elopement would have care plans including strategies and interventions to maintain safety, which was not fully implemented for this resident.
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.