Failure to Care Plan for Resident Elopement Risk After Actual Elopement
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, individualized plan of care addressing elopement risk for one resident. Facility policies on MDS/RAI/care planning, Resident Elopement, and Resident Elopement Follow-Up Procedure required that each resident have a written, individualized care plan and that any resident with a successful elopement be reassessed, with additional interventions identified and incorporated into the plan of care, including modifications for increased elopement risk and monitoring as needed. Review of the resident’s clinical record showed that an Elopement Risk Assessment was completed on 2/26/26 and identified the resident as being at risk for elopement. The resident, admitted on 11/7/14, had diagnoses including paranoid schizophrenia, diabetes, and high blood pressure. Information submitted by the facility showed that the resident eloped from the facility on 2/26/26. Despite this event and the completed Elopement Risk Assessment, review of the comprehensive plan of care did not reveal any care plan addressing the resident’s risk for elopement or the actual elopement. During an interview on 3/6/26, the RN Assessment Coordinator confirmed that the resident’s comprehensive plan of care did not include a care plan for elopement risk or the actual elopement, in contrast to the facility’s stated policies.
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