Failure to Implement Effective Elopement Prevention Measures
Summary
The facility failed to implement effective comprehensive care plan interventions for a resident at risk for wandering and elopement. The resident, who had a history of cerebral vascular accident and was cognitively intact with a BIMS score of 14, was left unattended on the facility's front porch. Despite wearing a Wander Guard, the resident exited the premises unnoticed and was later found at a grocery store approximately 0.3 miles from the facility. Interviews with facility staff, including the Director of Nursing, a CNA, and an LPN, confirmed that the resident was often left unattended on the porch, despite being at risk for elopement. The care plan for the resident, which included the use of a Wander Guard and regular checks, was not followed, leading to the resident's unsupervised departure from the facility. The State Agency identified an Immediate Jeopardy situation due to the facility's failure to adhere to its policy on elopement and wandering residents. The deficiency was noted as a serious risk to the resident's safety, as well as to other residents at risk for wandering and elopement.
Removal Plan
- A passerby notified Certified Nursing Assistant #1 that she observed an individual walking up the hill that she suspected to be a resident of the center. CNA #1 immediately came into the facility and notified the receptionist. A search by staff was initiated.
- The Center's Infection Control Preventionist got in her car to go off premises to look for Resident #1. Resident #1 was observed by the Infection Control Preventionist approximately a quarter mile from the facility outside a local grocery store and successfully encouraged to get in the car.
- Resident #1 returned to the facility.
- The Licensed Practical Nurse completed a body audit on the resident with no injuries noted.
- Resident #1 was placed on hourly staff monitoring for 24 hours.
- Licensed Nurses ensured all residents were in-house via visual observation.
- Education was initiated by the Director of Nursing and a Registered Nurse Supervisor on the elopement prevention policy to include the provision that any resident at risk for elopement will receive ongoing staff supervision while outside the center for all staff. No staff will be allowed to work until in serviced.
- The State Survey Agency and Attorney General's office was notified by the interim Director of Nursing.
- Resident #1, who is alert and oriented, was provided education by the Director of Nursing to notify staff anytime she wished to go outside or leave the center.
- The Director of Nursing and a Registered Nurse Supervisor completed elopement risk assessments on all residents to determine their risk of leaving the center without adequate staff supervision.
- The Quality Assurance and Performance Improvement (QAPI) Committee attended by the Director of Nursing, the Medical Director via phone, Infection Control Preventionist, and the Nursing Home Administrator updated the facility's policy on Elopement Prevention to include any resident at risk for elopement would receive ongoing staff supervision while outside the center.
- A new Nursing Home Administrator started.
- A Resident Council meeting was held by the Activities Director to provide education to residents to notify their licensed nurse and to sign out prior to leaving the center.
- Care plans on all residents at risk for elopement were reviewed and updates initiated by the Administrator and Minimum Data set (MDS) Coordinator to ensure they reflect individualized interventions for those residents at risk for wandering and elopement.
- The Director of Nursing initiated education on importance of accuracy of care plan interventions related to wandering/elopement prevention to Minimum Data Set Nurses (MDS), Infection Control Preventionist, Registered Nurse Supervisors, and Medical Records Coordinator.
- A 100 percent (%) Care Plan audit was conducted by the Administrator and MDS Nurses with updates for current interventions made to care plans to ensure compliance for residents at risk for elopement.
- Resident #1's care plan was updated by the MDS Coordinator with current interventions for elopement prevention.
- An Ad Hoc Quality Assurance meeting was held to discuss the Immediate Jeopardy Removal Plan and corrective actions, interventions, and education to ensure compliance. As part of the Ad Hoc QAPI Meeting, in-service completion for both the all-staff education on the elopement prevention policy and the importance of accurate and effective care plan interventions related to wandering/elopement prevention education for the Interdisciplinary Team (IDT) was reviewed by the Administrator and QAPI Committee Members with further instruction that no staff will be allowed to work until in serviced. It was attended by the Medical Director, Director of Nursing, Infection Control Nurse, Administrator, and RN Supervisor.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with paroxysmal atrial fibrillation, encephalopathy, severely impaired cognition, and documented moderate hearing difficulty with hearing aids did not have a care plan addressing hearing loss or hearing aid use. Review of the care plan showed no problem focus or interventions for hearing aid care or storage, despite MDS assessments indicating hearing needs. Staff confirmed there was no care plan for hearing loss, and the Administrator reported the resident’s hearing aids had been lost and later reordered. Facility policy required the IDT to periodically review and revise care plans based on resident needs, but this was not done for the resident’s hearing and hearing aid management.
Two cognitively intact residents with documented pressure ulcers on admission, including an unstageable ulcer that later progressed to stage II and a sacral pressure injury, did not have any corresponding pressure-ulcer care plans or interventions in their records. Review of progress notes and skin evaluations confirmed the presence of these wounds, while care plan review showed no entries addressing them. In an interview, the MDS coordinator and the DON acknowledged that the care plans did not include the residents’ pressure ulcers, despite facility policy requiring comprehensive care plans to be developed following resident assessments.
A resident with cognitive impairment and multiple comorbidities had recurrent redness and rash under the breasts, in the groin, and other skin folds documented repeatedly on shower sheets over an extended period, with notes that the condition had worsened and been present for months. A Wound NP later assessed the resident and diagnosed extensive fungal dermatitis with detailed measurements of affected areas. Despite this ongoing skin impairment and the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables, no such care plan or documented interventions specific to the rash were found in the medical record, as confirmed by the MDS nurse.
A resident with multiple chronic conditions, including dementia and Parkinson’s disease, was initially assessed as low risk for wandering but later scored as moderate and then high risk on wander-risk evaluations. Despite these increasing risk scores, the sections of the wander-risk tools designated for care plan interventions were left blank, and no elopement-risk care plan was initiated. The resident began self-propelling in a wheelchair and ultimately exited through an emergency exit door, triggering an alarm and sustaining an unwitnessed fall outside before being promptly found and assessed by staff. Interviews showed that an LPN completing the assessments had never filled out the intervention section, the MDS/RN relied on IDT judgment and did not care plan solely for wandering behavior, and leadership acknowledged that a care plan should have been implemented earlier in accordance with facility policy requiring care plan revisions when resident conditions change.
A resident with COPD, anxiety disorder, and osteoporosis, who had intact cognition but was dependent on staff for all ADLs, used a power wheelchair with a seatbelt for mobility. However, the resident’s care plan did not address the use of the power wheelchair or seatbelt, and the medical record contained no assessment of the appropriateness of the seatbelt. The DON and DOR confirmed both the resident’s use of the device and the absence of any related assessment or care plan, resulting in a deficiency in comprehensive care planning for device use.
A resident with a history of repeated falls and multiple comorbidities had a care plan that included non-skid strips on the floor beside the bed as a fall prevention intervention. During surveyor observation, the resident’s bedside area lacked these non-skid strips. A CNA, maintenance staff, and the DON each confirmed that non-skid strips were not in place, and maintenance reported that none were available in the facility. This failure to implement the care-planned intervention occurred despite a facility policy requiring comprehensive person-centered care plans to be developed and implemented.
Failure to Implement Person-Centered Care Plan for Hearing Loss and Hearing Aids
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing hearing loss and hearing aid use for a resident, as required by its care planning process. The resident was admitted with diagnoses including paroxysmal atrial fibrillation and encephalopathy, and an MDS 3.0 assessment initially documented minimal difficulty hearing with hearing aids, later showing severely impaired cognition, moderate hearing difficulty, and continued hearing aid use. Despite these documented needs, review of the resident’s care plan, last revised on 03/13/26, showed no problem focus related to being hard of hearing or wearing hearing aids and no interventions for hearing aid care or storage. Staff interviews confirmed the absence of a hearing loss/hearing aid care plan, and the Administrator reported that the resident’s hearing aids had been lost and subsequently reordered, with new aids arriving on 03/23/26. Policy review showed that the facility’s interdisciplinary team was required to periodically review and revise care plans based on resident goals, preferences, and needs, but this was not done for the resident’s hearing loss and hearing aid management. This deficiency was cited for failure to implement a comprehensive person-centered care plan for hearing aids and hearing loss for one resident reviewed for care plans, under Complaint Number 2802107.
Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
Failure to Develop Comprehensive Care Plan for Ongoing Fungal Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing an ongoing skin rash for a resident with multiple medical conditions, including cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy. A quarterly MDS assessment documented moderate cognitive impairment and a need for staff assistance with ADLs, but indicated no skin issues. However, repeated shower sheet documentation over the course of two months noted redness under both breasts and in the groin area, with staff recording that the redness had worsened and that it had been present for months. Interventions documented on the shower sheets were limited to lotion, powder, and brief notations, without evidence of a formal, measurable care plan. Further review of the medical record showed that a Wound NP later evaluated the resident and diagnosed extensive fungal dermatitis involving the skin folds under both breasts, the periumbilical area, groin, and buttocks, with specific measurements recorded for several affected areas. Despite this documented, ongoing rash and subsequent wound evaluation, there was no evidence in the medical record that a comprehensive person-centered care plan with measurable objectives and timetables was developed to address the skin impairment. The MDS nurse confirmed the absence of such a care plan or documented interventions to treat or prevent worsening of the rash, and the facility’s care plan policy required a comprehensive person-centered care plan for each resident to meet physical, psychosocial, and functional needs.
Failure to Timely Care Plan for Resident Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, measurable care plan addressing elopement risk for a resident identified as being at risk for wandering and elopement. The resident was admitted with multiple diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, and had a legal guardian. An initial wander-risk evaluation in late 2025 identified the resident as low risk for wandering, and an annual MDS assessment documented that the resident was cognitively intact, did not wander, and required partial to moderate assistance with ambulation using a wheelchair. A subsequent wander-risk evaluation in early 2026, completed by an LPN, showed the resident had progressed to a moderate risk for wandering, but the section of the form asking what interventions would be care planned was left blank. A discharge, return-anticipated MDS again documented that the resident did not wander and required partial to moderate assistance with ambulation. A later wander-risk evaluation in mid-February 2026, completed by an MDS/RN, identified the resident as high risk for wandering, and again the section for care plan interventions was left blank. On the same date, a progress note documented that the resident pushed on an exit door, activated the door alarm, and was found on his right side outside the emergency exit door with his wheelchair beside him after an unwitnessed fall; he was assessed and brought back to the nursing station for closer monitoring. A facility investigation confirmed that the resident had exited through an emergency exit door on a hall under construction and had been outside for less than five minutes, with alarms and egress doors functioning and staff responding immediately. Interviews with the LPN and MDS/RN revealed that nurses completed wander-risk assessments and the MDS/RN handled care planning, that the LPN had never completed the care plan intervention section of the wander-risk tool, and that the MDS/RN did not initiate an elopement risk care plan when the resident’s risk level increased from low to moderate because the IDT believed the resident was not an elopement risk. The Administrator and DON confirmed that a care plan should have been initiated when the resident began self-propelling around the facility and that this was not done until after the elopement event, despite facility policy stating that assessments are ongoing and care plans are revised as resident conditions change.
Failure to Care Plan and Assess Seatbelt Use with Power Wheelchair
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of a power wheelchair with a seatbelt for one resident. The resident was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and osteoporosis, and had intact cognition but was dependent on staff for all ADLs. Review of the resident’s care plan dated 12/12/25 showed no inclusion of the power wheelchair or seatbelt use, and the medical record lacked any assessment of the appropriateness of the seatbelt in the power wheelchair. During interviews, the DON and DOR confirmed that the resident used a power wheelchair with a seatbelt for mobility, that no assessment regarding seatbelt use had been conducted, and that the resident’s plan of care should have reflected the use of the seatbelt. These findings demonstrate that the facility did not develop and implement a complete, measurable care plan that addressed all of the resident’s needs related to the use of the power wheelchair and seatbelt, nor did it perform an assessment to determine the appropriateness of the device, resulting in a deficiency in comprehensive care planning for device use.
Failure to Implement Care-Planned Non-Skid Floor Strips for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The resident had multiple diagnoses, including multiple rib fractures, unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease. An annual MDS assessment documented that the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. The resident’s care plan, dated 08/14/24, identified fall risk related to refusing environmental modifications, self-medicating, alcohol use, use of mobility devices, and clutter in the room. Among the listed interventions were a cushion in the wheelchair, anti-roll backs to the wheelchair, encouraging use of the call light, a new bed/mattress, education on appropriate footwear, encouraging the resident to keep the bed in the lowest position, non-skid strips to the floor next to the bed, and family decluttering the room. Surveyor observation on 01/27/26 at 12:07 P.M. showed that the resident did not have non-skid strips on the floor beside the bed, despite this being a care-planned intervention. A CNA confirmed at the same time that there were no non-skid strips at the bedside. Later that day, a maintenance staff member verified that the resident did not have non-skid strips on the floor in the room and stated that non-skid strips would have to be ordered because none were available in the facility. On 01/28/26, the DON also confirmed that the resident did not have non-skid strips at the bedside as specified in the care plan. Review of the facility’s Comprehensive Person-Centered Care Plans policy, dated March 2022, indicated that each resident was to have a comprehensive care plan developed and implemented to meet physical, psychological, and functional needs. This deficiency was cited under a complaint investigation and was a recite to a prior annual survey.
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