Failure to Revise Care Plan Leads to Resident Elopement
Summary
The facility failed to revise the care plan for a severely cognitively impaired resident who eloped from the facility. The resident, who had a history of epilepsy and dependence on a wheelchair, was found approximately eight-tenths of a mile from the facility by police after being away for 81 minutes. The resident's care plan, last revised on 11/02/23, did not reflect his inability to go on leave of absence (LOA) unsupervised despite a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Staff interviews confirmed that the resident was no longer allowed to go out unsupervised due to his confusion, but this change was not updated in the care plan until after the elopement incident on 3/31/24. On the day of the incident, an agency LPN opened the door for the resident, mistakenly believing he was going to sit on the front porch. The resident exited the facility at 7:25 PM and was later found by police. The facility's Director of Nursing (DON) and Administrator were notified, and the resident was picked up and returned to the facility. Upon return, the resident was assessed with no injuries noted, and a wander guard bracelet was placed on his wrist. However, the failure to update the care plan in a timely manner directly contributed to the resident's unsupervised exit. Interviews with the Assistant Director of Nursing (ADON) and the Social Worker (SW) confirmed that the resident's BIMS score had been below 12 since 2/22/24, indicating severe cognitive impairment. Despite this, the care plan was not updated to reflect the resident's need for supervision during LOA. The SW acknowledged that the care plan should have been revised when the resident's BIMS score fell below 12, but it was not updated until after the elopement incident. The Interim DON also agreed that the care plan should have been updated at the time the resident was determined to be unsafe to go LOA unsupervised.
Removal Plan
- The interim Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 conducted a head-to-toe body assessment on Resident #1 to review for any skin abnormalities or concerns. Resident #1 had no negative skin issues or concerns.
- The Interim DON oversaw verification of all residents in facility using census with only one resident out of the facility and currently in the hospital. The census in the facility was 140.
- Staff present in the facility during the time of Resident #1 exit received immediate in-service by the Interim DON and Administrator on the procedures with residents signing out to exit facility to include verification of BIMS (Brief Interview for Mental Status).
- The Interim DON and Administrator initiated servicing with all staff present on Abuse, Neglect, Resident Rights, Vulnerable Adult, and Wandering. Staff Development will continue In-Servicing. No staff will be allowed to return to work without completing.
- Resident #1 wandering evaluation was reviewed by Interim Director of Nursing and indicated low risk for wandering. Resident #1 wandering evaluation was updated by the Interim DON and Administrator.
- The wander guard bracelet was verified to work properly by checking function with door alarm by Administrator, and then placed on Resident #1's left wrist.
- The facility camera was reviewed by the Administrator to determine the timeline of events leading up to Resident #1 exit of facility.
- The Administrator interviewed staff present of Resident #1 leaving the facility unattended. The agency LPN who held the door open stated that she was not aware he could not leave the facility.
- The Mississippi State Department of Health was notified of Resident #1 elopement.
- The Nurse Practitioner (NP) was notified by the Administrator of Resident #1 elopement and return to facility.
- Licensed nurses were notified to perform acute charting on Resident #1 every shift for the next 72 hours to review resident's physical, mental, and psychosocial needs.
- The LPN #1 initiated facility-based incident reporting on Resident #1.
- The Corporate Clinical Specialist (CCS) initiated an audit of the wander risk evaluations on all 140 active residents. Results indicated twelve (12) residents requiring updates to the wander system. All updates were corrected.
- The Social Services Director updated the wander and elopement binders to ensure all are reflective of results.
- The Maintenance Supervisor checked all wander guards to verify all were in correct working order with no issues found.
- The NP placed orders for Resident to obtain Urinalysis, Comprehensive Metabolic Panel, and Complete Blood Count.
- The Administrator performed an elopement drill to review and educate day shift on policies and procedures on elopement.
- Social Services completed a BIMS on Resident #1 which resulted in moderate cognitive impairment of a 9.
- A Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction.
- Resident #1 was assessed by the NP no issues found and care plan was updated by interdisciplinary team to reflect changes in leave of absence status.
- The Registered Nurse Supervisor #1 performed an elopement drill to review and educate night shift on policies and procedures on elopement.
- The Interim DON and Administrator Assistant performed an elopement Drill and educated staff on day shift.
- The Administrator Assistant developed an orientation binder for all agency staff onboard to be in-serviced on facilities policies and procedures to include wandering, elopement, where to find if a resident is allowed to out leave of absence, and appointment guidelines.
- NP reviewed results of labs ordered and placed an order for Levaquin 750 milligrams one by mouth at bedtime for 7 days related to Urinary Tract Infection to start.
- A current BIMS list will be in the leave of absence binder updated weekly or as needed by Social Services. All residents with BIMS under 12 will not be allowed to leave the facility without supervision.
- The final letter of investigation was sent to the Mississippi State Department of Health.
- The Attorney General was notified regarding the results of the Investigation.
- The Administrator performed an elopement drill to review and educate evening shift on policies and procedures on elopement.
- The Interim DON contacted Resident #2 general surgeon office to confirm phone for communication that is currently in their file and provide the facility contact information for any further communication.
- Resident Council Meeting was held with the Activity Director, Assistant Activity Director #1, Assistant Activity Director #2, and Resident Council President, and eighty-two (82) total resident presents to inform them the facility IJs.
- An in-service was initiated by Staff Development Coordinator on leave of absence process and how to locate residents BIMS. No staff will be allowed to return to work without signing.
- The Administrator held a one-to-one in-service with the Licensed Social Worker on Leave of Absences Care plans to include who can exit facility, supervision needed and process for a change in BIMS (Brief Interview for Mental Status).
- Medical Director, Administrator, Assistant Administrator, Interim Director of Nursing/ Infection Preventionist, and Assistant Director of Nursing held a Quality Assurance Performance Improvement Meeting to include notification of Immediate Jeopardy to review steps initiated to prevent any further reoccurrence to include audits on elopements, care plans, orientation binder, in-services on appointment process, audits of dialysis residents and contacting dialysis to verify appointments.
- Regional Case Mix conducted in-service with Minimum Data Set (MDS) to include implementation, Reviewing, Revising, and Resolving person-centered care plans.
- An audit was initiated by Social Services Director on leave of absence care plans to ensure resident with impaired cognition receive adequate supervision.
- The Assistant Administrator conducted a one-to-one in-service with Front Desk Receptionist to discuss appointment log, resident leave of absence binder, and how to locate current BIMS for residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
The facility failed to timely revise care plans when treatment needs changed for two residents. One resident with multiple conditions, including dysphagia and hypertension, had an antidepressant discontinued after refusal to take it, but the care plan continued to list the medication for depression and appetite without being updated. Another resident with significant respiratory diagnoses had orders for continuous O2 via nasal cannula, yet was repeatedly observed without the cannula in place. Staff reported frequent refusal of nasal cannula and BiPAP and verbal instructions to ensure use or document refusals, but there were no written notes or care plan updates addressing these refusal behaviors or directing staff response.
Surveyors found that the facility did not revise care plans to include new physician orders for two residents. One resident with a right leg fracture and edema had an order for a Tubi grip for edema management, but this intervention was not added to the care plan or TAR, and the resident was repeatedly observed without the Tubi grip in place despite reporting ongoing swelling. Another resident with COPD, depression, and cardiomegaly had a new order for continuous O2 at 3 LPM via NC, but the care plan still listed only older O2 orders at different settings and was not updated to reflect the current prescription.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Timely Revise Care Plans After Medication and Oxygen Therapy Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised timely and as needed when residents' conditions or treatments changed, contrary to its Resident Care Plan Revisions policy requiring prompt review and revision with any change in condition, response to treatment, or care needs. For one resident with hypertension, dysphagia, bilateral hearing loss, and other conditions, the care plan documented use of an antidepressant (Mirtazapine) for depression and appetite, last revised on 3/10/24. The Medication Administration Record showed that Mirtazapine was discontinued on 4/6/26 due to the resident’s refusal to take the medication, but the care plan was not updated to reflect this change. The CNO acknowledged that the care plan should have been updated when the antidepressant was discontinued. Another resident with pneumonia, diabetes, respiratory disorders, respiratory failure, shortness of breath, and pulmonary edema had a physician’s order dated 2/4/26 for continuous oxygen at 2 LPM via nasal cannula. The resident’s care plan directed staff to provide oxygen therapy as ordered via nasal cannula. However, the resident was observed on multiple occasions not wearing the nasal cannula while eating breakfast, lying in bed, and sitting in a chair. An LPN stated that the resident frequently did not wear her nasal cannula or BiPAP and that staff were verbally instructed to ensure she wore the nasal cannula or to document if she did not, but there were no corresponding notes in the medical record directing staff on these behaviors. A physician’s note later documented the resident’s refusal to wear the nasal cannula and BiPAP and a request to consider reducing oxygen requirements and/or orders, and the CNO stated the care plan related to nasal cannula and BiPAP refusal behaviors should have been updated at that time.
Failure to Update Care Plans for New Edema and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise resident care plans to reflect current physician orders and resident needs, as required by its Resident Care Plan Revisions policy. The policy, revised on 9/3/25, states that updates to the care plan will occur as needed based on the resident’s response to interventions or changes in condition. For one resident with a history including a right tibia fracture and anxiety, a physician order dated 3/6/26 directed edema management of the right lower leg with application of a Tubi grip in the morning and removal in the evening. On multiple observations on 3/30/26 and 4/2/26, the resident was seen sitting in her room without the ordered Tubi grip in place, and during an interview the resident reported that her right lower leg had been swollen for a while. Review of the resident’s care plan and Treatment Administration Record (TAR) on 4/2/26 showed no documentation of the Tubi grip order. A second resident, with diagnoses including COPD, depression, and cardiomegaly, had a physician order dated 3/9/26 for oxygen at 3 LPM continuously via nasal cannula using an oxygen concentrator and/or tank. Review of this resident’s care plan on 4/1/26 showed only prior oxygen interventions: oxygen via nasal prongs at 0–4 L PRN to maintain saturation at 90% or greater, initiated 2/10/25, and oxygen at 2 L/min continuously via nasal cannula, initiated 6/24/25. The more recent continuous 3 LPM oxygen order was not reflected in the care plan. In both cases, the CNO acknowledged that the residents’ care plans (and, for the first resident, the TAR) should have been updated to include the current physician orders but had not been revised.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
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