Failure to Develop Baseline Care Plan for Resident with Elopement Risk
Summary
The facility failed to develop a baseline care plan for a newly admitted resident with a known history of elopement. The resident, who had a recent diagnosis of Dementia and Alzheimer's with worsening Frontotemporal Dementia, was admitted to the facility and was not properly assessed or monitored for elopement risk. Despite the resident's history of wandering and elopement, no baseline care plan was created to address these risks, and the staff was not informed of the resident's elopement risk. On the day of admission, the resident eloped from the facility unnoticed and unsupervised. The resident was last seen in his room at 4:38 PM and was later found by the local police department at a nearby business at 6:01 PM. The resident had left the facility through a window in his room. Interviews with various staff members, including the Director of Nurses, Certified Nurse Assistant, Licensed Practical Nurses, and Registered Nurses, confirmed that the resident's care plan was not completed, and the staff was unaware of the resident's elopement risk. The facility's failure to develop and implement a baseline care plan for the resident placed the resident and other residents at risk for wandering and elopement. This deficiency was identified as an Immediate Jeopardy by the State Agency, indicating a situation likely to cause serious injury, harm, impairment, or death. The facility's policies and procedures for elopement and missing residents were not effectively followed, leading to the resident's unsupervised elopement.
Removal Plan
- Resident #1 was placed on one-on-one supervision until transferred to hospital for geriatric psychiatric services.
- Policy committee reviewed the Elopement and Missing Resident policies, no changes were made.
- Directive Inservice was initiated by Licensed Nursing Home Administrator from an outside facility. Content of in-service Elopement and Missing Resident policies. Identifiers and Communication for High-Risk Elopement Residents. Identifiers include Elopement Evaluation User Defined Assessment, resident care profile on the Point Click Care dashboard, the Point of Care, and the Elopement Binders. No staff will be allowed to work until in-serviced.
- Director of Nursing conducted 100% care plan audit of all residents with elopement risk, 8 total. No issues found.
- The Maintenance Director conducted 100% audit of all resident room windows to ensure they are secure, all windows are secure.
- State Department of Health was notified of elopement via complaint hotline. Attorney General notified via web portal. Police Department had been notified by neighboring business and were with resident.
- Per facility protocol all admissions are assessed for elopement risk, all new admissions will have a baseline care plan within 48 hours of admission, residents who are at high risk for elopement are photographed and added to the elopement binders located at the reception desk and both nursing stations, an order is added for nursing to monitor for elopement, high risk elopement residents are added to the Point of Care for hourly monitoring. A review of high-risk elopement residents is completed weekly during Facility High Risk Meetings to ensure identifiers are present.
- Elopement risk has been added to the resident care profile on Point Click Care dashboard.
- Elopement risk has been added to the Point of Care Kardex.
- The facility has implemented secure conversation via electronic system to be utilized to notify staff of all admissions including those who are high risk for elopement.
- Emergency Quality Assurance meeting held via phone conference. The unusual occurrence was discussed, all events before, during and after occurrence were reviewed. Committee members placed Resident #1 on one-on-one monitoring until transferred to a hospital.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not follow its baseline care plan policy requiring that a written summary of the baseline care plan be given to the resident and/or representative and that this be documented in the medical record. For three newly admitted or readmitted residents with conditions including muscle wasting with respiratory failure, Parkinson’s disease with prostate cancer, and a stable lumbar fracture with repeated falls, there was no documentation that a baseline care plan was provided or discussed. During interview, the RNC acknowledged that there was no record showing these residents or their representatives had received copies of their baseline care plans.
The facility did not complete and lock baseline care plans within 48 hours of admission for two residents with conditions including chronic respiratory failure, dementia, diabetes, and need for assistance with personal care, contrary to facility policy. In addition, the facility did not document that baseline care plans were provided and discussed with five cognitively intact or medically complex residents, including those with COPD, CKD, bipolar disorder, anxiety, interstitial lung disease, heart failure, and obstructive sleep apnea, or with their representatives. The CNO acknowledged that required baseline care plans were either not completed timely or not documented as shared with residents or their representatives.
A resident was admitted and did not receive a written or verbal summary of the baseline care plan, as required by facility policy. Record review showed no documentation that the resident or the resident’s representative was given baseline care plan information within the required timeframe. The SSD acknowledged that no baseline care plan conference note was completed, no care plan conference had occurred since admission, and no phone contact was made with the resident’s representative to convey baseline care plan details, despite the resident having generally intact cognition. This was inconsistent with the facility’s policy requiring development of a baseline plan of care within 48 hours of admission and provision and documentation of a written summary to the resident and/or representative.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident admitted with a history of falls and a right pelvic fracture had physician orders for non-weight bearing to the right leg, but the baseline care plan developed within 48 hours did not include the pelvic fracture or non-weight bearing status. Instead, the resident was care planned only as high risk for falls due to reduced mobility and poor safety awareness, with general interventions such as low bed position, call light within reach, and staff assistance as needed. During surveyor interview, the DON confirmed that the non-weight bearing and specific transfer requirements were omitted from the baseline care plan, despite hospital records with these orders being available prior to admission.
Failure to Provide and Document Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to provide baseline care plans to residents or their representatives and to document this provision in the medical record for three of five residents reviewed. Facility policy "Care Plans - Baseline," version 1.2, required that the resident and/or representative be provided a written summary of the baseline care plan in an understandable language and that provision of this summary be documented in the medical record. For a resident admitted with muscle wasting and respiratory failure, there was no documentation that a baseline care plan was provided or discussed with the resident or representative. For a second resident admitted with Parkinson’s disease and malignant neoplasm of the prostate, the medical record likewise lacked documentation that a baseline care plan was provided or discussed. For a third resident, initially admitted and later readmitted with a stable lumbar vertebral fracture and repeated falls, there was also no documentation that a baseline care plan was provided or discussed. On interview, the RNC confirmed there was no documentation that these residents or their representatives had received copies of their baseline care plans. This deficiency centers on the facility’s noncompliance with its own baseline care plan policy and the absence of required documentation in the medical records for multiple residents with significant medical conditions.
Failure to Complete and Share Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete and lock baseline care plans within 48 hours of admission for two residents and failed to provide and document provision of baseline care plan summaries to several other residents or their representatives. Policy revised 9/3/25 required initiation of a baseline care plan for each resident within 48 hours of admission, and that the facility review and provide the resident and/or representative with a summary of the baseline care plan and provider orders in an understandable language, with evidence of this in the medical record. Resident #4, admitted with chronic respiratory failure with hypoxia and dementia, had a baseline care plan that was not signed and locked until four days after admission, and the CNO confirmed it should have been completed and locked within 48 hours. Resident #70, initially admitted and later readmitted with diabetes and a need for assistance with personal care, had no baseline care plan documented in the medical record, which the CNO also confirmed. The facility also did not document that baseline care plans were provided and discussed with five residents or their representatives. Resident #7, with bipolar disorder and anxiety and assessed as cognitively intact on a quarterly MDS, had a 48-hour care plan form that did not document that she or her representative received a copy of the baseline care plan. Resident #9, with COPD and chronic kidney disease and documented as cognitively intact on a comprehensive MDS, had no documentation in the medical record that a baseline care plan was provided and discussed with her or her representative. Residents #11, #21, and #28, each with multiple diagnoses including COPD, obstructive sleep apnea, interstitial lung disease, heart failure, and COPD, similarly had no documentation that their baseline care plans were provided and discussed with them or their representatives. The CNO stated there was no documentation that these residents or their representatives had received copies of their baseline care plans.
Failure to Provide and Document Baseline Care Plan Summary After Admission
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative received a copy of the resident’s baseline care plan following admission. Record review for Resident 8 showed that the resident was admitted on an identified date, but the clinical record did not contain documentation that a written summary of the baseline care plan was provided to the resident or the resident’s representative. The facility’s policy, dated 8/2024, required that a baseline plan of care to meet the resident’s immediate health and safety needs be developed within 48 hours of admission and that the resident and/or representative be provided a written summary of this baseline care plan, with documentation of this provision in the medical record. During interviews, the Social Services Director (SSD) stated that she had not completed a baseline care plan conference review note for Resident 8 because the resident had not yet had a care plan conference since admission, and therefore no baseline care plan information was provided to the resident or the resident’s representative. The SSD further indicated that baseline care plan information was to be conveyed to residents or their representatives within 72 hours after admission and could be relayed over the phone, but no phone contact was made with Resident 8’s representative. Although Resident 8’s cognitive status was intact, with some fluctuation in cognitive function, the SSD did not provide baseline care plan information verbally or in writing to the resident. This failure was contrary to the facility’s written policy and the requirement to document provision of the baseline care plan summary in the medical record.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Include Non-Weight Bearing Status in Baseline Fall Care Plan
Penalty
Summary
The facility failed to follow its baseline care plan policy and did not ensure that required diagnoses and interventions related to fall risk were included in a newly admitted resident’s baseline care plan. The resident was admitted with diagnoses including a history of falling and a right pelvic fracture, with physician orders specifying non-weight bearing to the right leg. Despite these documented conditions and orders, the baseline care plan developed within the first days after admission identified the resident as high risk for falls only in relation to reduced mobility and poor safety awareness, and did not include the right pelvic fracture or the non-weight bearing status of the right leg. The baseline care plan interventions focused on general fall prevention measures such as keeping the bed in the lowest position, placing frequently used items and the call light within reach, and having staff assist as needed. These interventions did not address the specific non-weight bearing and transfer requirements associated with the resident’s right pelvic fracture. During an interview, the DON reviewed the baseline care plan and confirmed that the non-weight bearing right leg and pelvic fracture were not included, even though the hospital records with the non-weight bearing order had been received prior to admission. This omission occurred despite the facility’s written policy requiring that the baseline care plan, developed within 48 hours of admission, include necessary information such as fall risk to properly care for the resident.
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