F0656

D

Failure to Implement Elopement Care Plan Interventions for Two Residents

Troy, New York Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement comprehensive, person-centered care plan interventions for two residents identified as being at risk for wandering and elopement, resulting in both residents leaving the facility without appropriate supervision. The facility’s care plan policy dated 06/20/2025 required interdisciplinary care plans with measurable objectives and timeframes to meet residents’ identified needs. For one resident with diagnoses including alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence, the comprehensive care plan for "Behavior Problem: Wandering and Elopement risk" dated 10/15/2025 set a goal that the resident would be maintained safely under staff supervision and remain within the facility unless escorted by family or staff. Interventions included documenting and notifying providers of the intensity, duration, or frequency of behavior and redirecting the resident. Despite this, progress notes and interviews showed repeated expressions of the resident’s desire to leave and escalating behaviors without corresponding documented implementation of enhanced supervision or redirection sufficient to prevent elopement.

Progress notes documented that on 10/16/2025 the resident stated they wanted to leave against medical advice due to not receiving pain medication but were convinced to stay. On 10/17/2025 at 6:33 AM, an LPN noted the resident was walking up and down the hallway demanding medication, and later that morning another LPN documented that the resident attempted to leave through the front door several times, yelling and being aggressive, but was calmed. A late entry note on 10/18/2025 at 11:43 AM stated the resident was yelling about pain medication, walked to the lobby, sat in a chair by the door, and fell asleep. The same note indicated that later the resident could not be found in their room or in the lobby, and the DON, medical provider, and health care proxy were notified that the resident had left against medical advice. Interviews with CNAs confirmed the resident had repeatedly stated a desire to leave because they found the facility too restrictive, and that this was reported to nursing staff. The overnight LPN reported last seeing the resident in the lobby around 6:00 AM and did not have a discussion with the resident about leaving against medical advice or obtain any signed forms. The DON stated that because the resident was alert and oriented, the facility had no responsibility if the resident wanted to leave, did not consider the incident an elopement, and stated the resident did not need to be supervised and was allowed to leave at any time, despite the existing care plan for wandering and elopement risk.

For the second resident, who had diagnoses of unspecified Alzheimer’s disease, cognitive communication deficit, and generalized muscle weakness, the MDS dated 11/26/2025 documented that the resident could be understood and could understand others but had severely impaired cognition. The resident’s care plan titled "Wandering/Elopement" effective 11/03/2025 documented that the resident was at risk for wandering into unsafe areas or eloping out of the building without supervision, with a goal that the resident would be maintained safely under staff supervision and remain within the facility unless escorted by family or staff over the next 30 days. Interventions included identifying patterns of behavior, documenting intensity, duration, or frequency of behavior in progress notes, orienting the resident to daily routines, referring for psychiatric consult per MD order, and ensuring proper placement and functioning of an ankle alert device. Despite these planned interventions, an incident report submitted to the state on 11/16/2025 documented that the resident was able to leave the facility. A dietary aide reported seeing the resident alone outside near the north rehabilitation door in their wheelchair and immediately notifying a supervisor. The DON stated that the door used was an alarmed emergency exit, not a WanderGuard-alarmed door, and also stated that it was the shared responsibility of all staff to know and implement care plans, and that when care plans are updated, the person updating them is responsible for ensuring CNA care cards are updated. The events show that the care plan interventions, including supervision and use of the ankle alert, were not effectively implemented, allowing the resident to elope.