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:
Baseline Care Plan Missing Oxygen and Bi-Pap Needs: A resident admitted with acute respiratory failure with hypercapnia, COPD, and dependence on supplemental O2 did not have a baseline care plan completed within 48 hours to include O2 administration or bi-pap use. The ADON initiated the plan but did not add these needs, and an LVN caring for the resident was unaware he used bi-pap nightly.
Baseline Care Plan Missing Enteral Feeding Instructions: A resident admitted with pneumonitis, stroke, and hemiplegia had an order for Isosource 1.5 via enteral feeding, but the admission observation and baseline care plan failed to identify the gastric/enteral tube and did not include instructions for gastrostomy tube or enteral feeding care. The RN consultant confirmed the baseline care plan was not developed and implemented to include the needed instructions for effective, person-centered care.
Failure to Review and Offer Baseline Care Plans Within 48 Hours: The facility did not document that baseline care plans were reviewed with the resident or representative and a copy offered within 48 hours for three newly admitted residents. The DON stated one resident’s care plan copy was not available, and the lead social services coordinator said baseline care plans were typically reviewed at the admission care conference, usually 7 to 14 days after admission, and she did not know the 48-hour requirement.
A resident admitted after being found unresponsive had diagnoses including psychoactive substance abuse, major depression, and quadriplegia, with hospital testing positive for cocaine and fentanyl. The admission assessment noted intact cognition and regular drug use, but the record had no baseline care plan for substance use prevention, monitoring, or treatment interventions, and an MDS LPN confirmed no related plan of care was present.
A facility failed to provide a written summary of the baseline care plan to two residents and/or their representatives within the required timeframe. One resident had diagnoses including a lumbar fracture, morbid obesity, and cirrhosis of the liver, while the other had UTI, DM, and ataxic gait. The NHA confirmed there was no evidence the required baseline care plan summary was provided.
Baseline Care Plan Not Completed Within Required Timeframe: A resident with severe dementia, a BIMS score of 0, and needs for partial to moderate ADL assistance did not have a baseline care plan in the EHR within the required timeframe after admission. Staff interviews showed the MDS nurse, ADON, and DON had differing descriptions of who completed the plan and when, and the record review showed no care plan present initially and only a later-restored entry with a single FULL CODE focus.
Baseline Care Plan Missing Oxygen and Bi-Pap Needs
Penalty
Summary
The facility failed to develop Resident #56’s baseline care plan within 48 hours of admission to include supplemental oxygen use and bi-pap use. Resident #56 was admitted with diagnoses including acute respiratory failure with hypercapnia, COPD, cerebral infarction, and dependence on supplemental oxygen. The resident’s record showed oxygen orders for 2 to 4 liters per nasal cannula beginning on the admission date, and during observation he was wearing oxygen at 3 liters per nasal cannula, denied shortness of breath, and stated he used a bi-pap machine every night for 5 to 6 hours. The baseline care plan was initiated on 08/07/2026 but did not address oxygen administration or bi-pap use. The LVN caring for the resident on day shift said she was aware he was receiving oxygen therapy but was unaware he was on a bi-pap machine. The ADON said she admitted the resident and was responsible for opening the 48-hour baseline care plan, but she did not add oxygen use or bi-pap to it. The DON said the admitting nurse was responsible for initiating the baseline care plan and stated the ADON did not trigger all items that would have completed the 48-hour care plan.
Baseline Care Plan Missing Enteral Feeding Instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, R181, to include instructions needed to provide effective and person-centered care. The facility’s Interim Baseline Care Plan Policy dated 5/4/26 stated that an interim/baseline care plan would be developed and implemented within 48 hours of admission for each resident until a comprehensive assessment could be completed. R181 was admitted with diagnoses of pneumonitis, stroke, and hemiplegia. A physician order dated 7/31/26 indicated Isosource 1.5 enteral feeding at 60 ml/hr with confirmation of total volume to infuse. However, the Nursing-Admission/readmission Observation 3 document dated 7/31/26 at 2:39 p.m. documented that the resident did not have a gastric/enteral tube, and the GI appliances section failed to mark a gastrostomy tube as present. The baseline care plan section stated dietary needs would be met as ordered but did not specify the need for gastrostomy tube and/or enteral feedings. During interview on 8/7/26 at 11:10 a.m., the Regional Nurse Consultant confirmed the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care for R181.
Failure to Review and Offer Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that the baseline care plan was reviewed with the resident or the resident’s representative and that a copy was offered within 48 hours of admission for three newly admitted residents. Review of the electronic medical record for resident 9 showed admission to the facility on [DATE], but there was no documentation that the baseline care plan was reviewed with the resident or representative or that a copy was offered within 48 hours. A copy of resident 9’s baseline care plan was requested from the facility on 7/29/26, and the DON later stated that a copy was not available. Review of the records for residents 3 and 12 also showed admission to the facility on [DATE], with no documentation that either resident’s baseline care plan was reviewed with the resident or representative or that a copy was offered within 48 hours of admission. The lead social services coordinator stated that baseline care plans were started by the MDS nurse or clinical care leader upon admission, but she reviewed and offered the care plan during the admission care conference, which usually occurred seven to fourteen days after admission. She acknowledged there was no documentation that residents 3 or 12 had their baseline care plans reviewed and offered within 48 hours, and stated she did not know the regulation required this to occur within that timeframe.
Missing Baseline Care Plan for Substance Use Disorder
Penalty
Summary
The facility failed to develop a baseline care plan at admission to address a resident’s substance use disorder. Resident #2 was admitted from the hospital after being found unresponsive, with diagnoses including cervical disc displacement, quadriplegia, central cord syndrome, altered mental status, conversion disorder with seizures, psychoactive substance abuse, major depression, and hypertension. Hospital referral documentation noted the resident had been admitted due to concerns for an episode of unresponsiveness, potentially secondary to a cerebral vascular event versus seizure-like activity, and that a drug screen was positive for cocaine. Hospital diagnoses also included polysubstance abuse, and laboratory blood testing showed a positive fentanyl result. The nursing admission assessment documented that the resident had intact cognition and used drugs regularly. However, the record contained no baseline care plan identifying substance use prevention, monitoring, or treatment interventions. During interview, the MDS Coordinator verified that the resident’s medical record had no plan of care related to substance abuse. This deficiency affected one resident out of five reviewed for care plan development, and the facility identified 16 residents with a history of substance use disorder in a census of 64.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to the resident and/or representative for two residents reviewed. Facility policy stated that a baseline plan of care to meet a resident’s immediate health and safety needs is to be developed within 48 hours of admission and include the minimum healthcare information needed to properly care for the resident, including initial goals, physician orders, dietary orders, therapy services, and social service information. Resident R94 was admitted with diagnoses of fracture of the first lumbar vertebra, morbid obesity, and cirrhosis of the liver. The clinical record lacked evidence that a written summary of the baseline care plan was reviewed 14 days after admission. Resident R78 was admitted with diagnoses of urinary tract infection, diabetes mellitus, and ataxic gait. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. During interview, the NHA confirmed there was no evidence that the written summary of the baseline care plan was provided to either resident within the required timeframe.
Baseline Care Plan Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #7 within 48 hours of admission. Resident #7 was an [AGE] year old male admitted with diagnoses including spondylolysis of the lumbar region, unspecified severe dementia with other behavioral disturbance, and major depressive disorder. His quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented that he required partial to moderate assistance with most ADLs. The order summary also included an active telephone order stating that the resident or resident representative had been informed of the medical condition and plan of care. Record review on 07/21/2026 showed no care plan present in the electronic health record for Resident #7. Later review on 07/24/2026 showed a care plan that appeared to have been initiated on 05/09/2026, but the historical view showed an actual initiation date of 07/24/2026. The only item listed was "Focus. I chose to have FULL CODE." During interview, the MDS nurse stated that the baseline care plan is done with the admitting nurse to cover the first 72 hours and that she had accidentally deleted the existing baseline care plan earlier that day, then restored it. The ADON stated that within the first 24 hours the admitting nurse is to complete the baseline care plan with RN oversight, and the DON #2 did not verify that a baseline care plan was present for Resident #7. The facility policy stated that a baseline plan of care to meet the resident's immediate needs shall be developed within 48 hours of admission.
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