Failure to Maintain Comprehensive Care Plans for Hospice and Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain individualized, comprehensive, person-centered care plans addressing all identified needs for two residents. One resident with Alzheimer’s disease, dementia, prior cerebral infarction with hemiplegia, atrial fibrillation, and a history of transient ischemic attack was cognitively impaired and had a physician order for a hospice consult. The DON stated that this resident should have a comprehensive person-centered care plan tailored to hospice care to ensure collaboration with the hospice team and that her end-of-life wishes were respected and met. However, review of the resident’s comprehensive care plan and EMR showed no documentation of hospice and no hospice care plan in place, despite the facility’s Comprehensive Care Plan policy requiring development and implementation of a comprehensive person-centered care plan for each resident. The second resident had vascular dementia with severely impaired cognition, documented wandering behavior occurring 4 to 6 days during the MDS assessment period, and multiple progress notes describing incidents of being found in stairwells, near exits, or on different units, with documented wandering and exit-seeking behavior. Elopement Risk & Community Survival Skills Assessments identified this resident as at risk to elope, indicated placement on the Elopement Risk Protocol, and stated that a care plan for elopement was indicated. Staff interviews confirmed the resident’s history of wandering, exit-seeking, and ongoing elopement risk. Despite this, the current care plan did not contain focuses for wandering or elopement risk. The MDS Coordinator confirmed the absence of these focuses, and the Social Service Director stated that the EMR had resolved or cancelled the wander/elopement risk care plan earlier in the year and it was not reinstated until the date of the survey, leaving the resident without an active care plan addressing elopement risk for a period of time.
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