Failure to Implement Wandering Care Plan Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to follow an established care plan for a resident identified as being at risk for wandering and elopement, which resulted in an elopement incident. The resident had multiple diagnoses, including encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, and anemia, and the History and Physical documented that the resident did not have the capacity to understand and make decisions. An MDS assessment indicated short- and long-term memory problems, with the resident requiring varying levels of assistance for ADLs. An Elopement Risk Evaluation dated 3/8/26 identified the resident as at risk for elopement, with comments specifying use of a Wanderguard and frequent visual checks. A wandering risk care plan initiated the same day included interventions such as a bracelet alarm for alarmed doors, checking the resident’s location every 30 minutes, and ensuring all staff were aware of the elopement risk. Despite these identified risks and care plan interventions, the facility did not implement the ordered Wanderguard or ensure monitoring consistent with the care plan prior to the elopement. A registered nurse supervisor reported receiving a physician’s order for a Wanderguard and, because the resident could not consent, contacting the resident representative for consent and endorsing follow-up to the next shift. Progress notes for the following day showed no evidence that any shift followed up on obtaining consent or implementing the Wanderguard before the resident eloped in the early morning hours of 3/10/26. A LVN confirmed that there was no order in the order summary for monitoring a Wanderguard or wandering behaviors through 3/17/26, and therefore no related documentation or monitoring occurred. The facility’s own wandering and elopement policy stated that residents at risk would have care plans including strategies and interventions to maintain safety, but the documented interventions were not carried out for this resident.
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