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:
A resident admitted after hospitalization for a MDR UTI was receiving IV meropenem through a PICC line and required contact isolation precautions and an indwelling catheter. Although the admission report and nurse-to-nurse handoff documented these needs, the baseline care plan did not include the PICC line or isolation precautions among the resident’s immediate care needs. Staff interviews confirmed the resident arrived with these treatments and precautions in place, and the DON stated the expectation was for a baseline care plan to be developed and implemented within 24 hours of admission.
A resident admitted with schizoaffective disorder, HIV, bipolar disorder, and insomnia did not have a baseline care plan developed within the required 48 hours. The Unit Manager confirmed she was responsible for completing and tracking baseline care plans, and verified the resident’s plan was not completed on time.
A resident admitted with traumatic subdural hemorrhage, T5-6 vertebral fractures, and respiratory failure did not have a baseline care plan with instructions for positioning, bed mobility, or transfers within 48 hours of admission. The EHR and bedside Kardex lacked guidance for nursing staff, and observations showed the resident slouching in bed and later with feet touching the lower bed frame. An LPN and the DON both stated the care plan did not meet expectations.
A resident admitted with asthma, hypothyroidism, and HTN did not have evidence in the record that a written summary of the baseline care plan and order summary was provided to the resident and/or representative. The NHA confirmed the missing documentation during interview.
A resident with hemiplegia, severe cognitive impairment, a feeding tube, and surgical wounds was ordered EBP for a PEG tube, but the care plan did not include the EBP need or related interventions. The DON confirmed the omission and stated that the care plan is meant to communicate interventions for resident safety, protection, and care.
Failure to Develop Baseline Care Plans Within 48 Hours: The facility did not open baseline care plans within the required timeframe for three residents reviewed for abuse and falls. One resident’s abuse care plan was started well after admission and the baseline plan did not include abuse. Another resident’s abuse/neglect plan was started after an abuse allegation, and a third resident with a high fall risk score had no baseline fall care plan despite a fall and an abuse allegation after admission. The Care Plan Coordinator confirmed the baseline plans were not in place as required.
Baseline Care Plan Missing PICC Line and Contact Isolation Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #31 that included the instructions needed to provide effective and person-centered care for his immediate needs. Resident #31 was admitted on 5/22/2026 after a hospitalization for a multi-drug-resistant organism UTI and was receiving IV meropenem through a PICC line. He also required contact isolation precautions and had an indwelling urinary catheter noted in the admission record and MDS. The record showed that the admission report completed by LVN B documented that Resident #31 needed contact isolation precautions and IV meropenem, and nursing progress notes documented that Resident #31 was admitted with a PICC line present in the right antecubital area. However, the baseline care plan dated 5/22/2026 did not include the PICC line or infection control isolation contact precautions among the resident's immediate care needs. During interviews, RN D stated the resident was being discharged from the hospital with a contact isolation room, a PICC line, and an indwelling catheter, and LVN B stated she received report from the hospital RN and documented the resident's need for contact isolation and meropenem. LVN A stated that standard practice was to develop a baseline care plan for newly admitted residents to meet their basic immediate needs within 24 hours, and that a PICC line would require flushing to keep it patent. The DON stated the expectation was for newly admitted residents to receive immediate care needs through a baseline care plan developed and implemented within 24 hours of admission, coordinated by the IDT. The facility policy also stated that care plans would be developed within the timeframe required by applicable regulations and include identified problems and needs, interventions, and responsible disciplines and staff.
Failure to Complete Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care within 48 hours of admission for Resident #78. Resident #78 was admitted on 05/29/2026 with diagnoses including Schizoaffective Disorder, Unspecified; Asymptomatic Human Immunodeficiency Virus; Bipolar Disorder; and Insomnia. Review of the medical record showed that Resident #78 did not have a baseline care plan. During interview, Resident #78 stated he was new to the facility and had recently been admitted. The Unit Manager stated she was responsible for completing baseline care plans, including follow-up to ensure they were completed within the required 48-hour timeframe, and confirmed that Resident #78's baseline care plan was not developed or completed within 48 hours, although it should have been.
Baseline Care Plan Not Completed for Bed Mobility and Transfers
Penalty
Summary
The facility failed to formulate a baseline care plan within 48 hours of admission for Resident 159, who was admitted with traumatic subdural hemorrhage, fractures of the T5-6 vertebrae, and respiratory failure and was not able to communicate needs. Review of the electronic health record showed the resident’s care plan dated 05/10/2026 contained no instructions or directions for positioning in bed, bed mobility, or transfers, and the Visual/bedside Kardex also had no instructions for nursing assistants on bed mobility and transfers. Observations showed the resident in bed with the head of the bed elevated and the body slouching down on 05/18/2026, and again in bed with the head of the bed elevated and the feet touching the lower bed frame on 05/20/2026. During interview, the LPN/Resident Care Manager stated the baseline care plan should have included directions and instructions on bed mobility and transferring, and the DON stated the care plan did not meet expectations.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to Resident R1 and/or the resident’s representative within the required timeframe after admission. Resident R1 was admitted on 10/7/25 with diagnoses including asthma, hypothyroidism, and hypertension. Review of the clinical record found no evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or representative. During an interview on 5/28/26 at 3:11 p.m., the Nursing Home Administrator confirmed there was no evidence that the written summary of the baseline care plan and order summary had been provided.
Failure to Include EBP for PEG Tube in Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident who was on enhanced barrier precautions related to a PEG tube. Resident #1 was admitted with diagnoses including hemiplegia affecting the nondominant side, need for gastrostomy care, and need for assistance with personal care. The resident’s MDS dated 04/10/2026 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and also documented a feeding tube present on admission and surgical wounds. The Order Summary Report showed an order for enhanced barrier precautions related to the resident’s PEG tube, with an order date of 04/03/2026. Review of the resident’s care plans did not show a focus or interventions addressing the need for enhanced barrier precautions. During interview, the DON stated that the purpose of the care plan was to communicate appropriate interventions for resident safety, protection, and care, confirmed that the resident was on EBP because of the PEG tube, and acknowledged that the need for EBP was not included in the care plan.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents reviewed for abuse and falls. For one resident, admitted on [DATE], the potential for abuse care plan was not initiated until 4/27/26, 18 days after admission, and the Care Plan Coordinator stated that baseline care plans should be opened by nurses within 72 hours and developed within 48 hours. When the surveyor asked whether the baseline care plan included abuse, the EMR showed it did not, and the abuse care plan was not initiated until 4/27/26. For another resident, admitted on [DATE], a facility-reported incident documented an allegation that the resident overheard two staff members saying they would choke her out. The abuse/neglect care plan was not initiated until 3/25/26, after the allegation and 6 days after admission, and the baseline care plan did not include abuse. For a third resident, admitted on [DATE], the admission fall risk evaluation showed a score of 11, indicating high risk. The resident had a fall on 5/16/26 when staff found her on the floor beside her bed, yet the fall care plan was not initiated until 5/18/26. The resident also had an abuse allegation on 5/14/26 when her husband stated a CNA allegedly yelled at her, and the abuse care plan was not initiated until 5/17/26. The Care Plan Coordinator stated the resident did not have a baseline fall care plan and that only the comprehensive abuse care plan was available.
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