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 dementia, muscle weakness, and protein-calorie malnutrition had a care plan directing staff to offload his heels or use Prevalon boots while in bed. During observation, he was found in bed without the boots, and an LPN confirmed his heels were not offloaded even though they should have been.
Failure to care plan depression: A resident with MDD and ongoing depressive symptoms had psychology evaluations documenting depressed mood, loss of interest, sleep disturbance, fatigue, and appetite changes, and the MDS listed depression as an active dx. However, the care plan did not include depression as a focus area, and the MDS Coordinator and DON both stated it should have been care planned.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A facility failed to include person-centered comprehensive care plan focus areas for two residents receiving ordered meds. One resident with atrial fibrillation was receiving Eliquis, and another resident with insomnia was receiving Trazodone, but neither current care plan addressed the medication use. The MDS Nurse stated she was responsible for care plan development and said the omissions were due to oversight.
Failure to update a resident’s fall care plan with a Geri-chair intervention. A resident with dementia, osteoarthritis, diabetes, severe cognitive impairment, and a history of falls had a care plan listing multiple fall precautions, but after a witnessed fall and a physician order for a Geri-chair or tilt back WC, the care plan was not updated to include that intervention. Surveyors observed the resident in a Geri-chair, and the MDS Coordinator and DON acknowledged the care plan had not been updated.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to Offload Heels as Directed
Penalty
Summary
Resident #32, who was admitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition, had a care plan revised on 6/18/21 directing staff to offload his heels or use Prevalon boots when he was in bed, as he allowed. During observation on 7/9/26 at 11:22 AM, Resident #32 was found in bed without Prevalon boots in place. At 11:23 AM, an LPN stated the resident should have had his boots on, then lifted the blanket and observed the resident's legs resting on a pillow. When asked whether the resident's heels were offloaded, the LPN stated they were not and confirmed they should have been offloaded.
Failure to Care Plan Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, who had diagnoses including Major Depressive Disorder and was documented by psychology evaluations as having recurrent, moderate depression. The resident’s evaluation notes described decreased interest in activities, persistent depressed mood, sleep disturbances, fatigue, and changes in appetite, with symptoms occurring on more than half of the days and causing moderate subjective distress. A later psychology note again documented persistent depressed mood, marked loss of interest, altered sleep patterns, and fatigue with moderate distress. The resident’s quarterly MDS dated 6/13/2026 documented an active diagnosis of depression in Section I, but the care plan did not include a focus area for depression. During interview, the MDS Coordinator stated the resident had been followed by Balance Wellbeing since 12/2025, the diagnosis was entered on 5/20/2026, and depression was not included in the care plan but should be. The DON also stated the resident should be care planned for depression. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs and all services identified in the comprehensive assessment.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. The facility's policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Missing Care Plan Focus Areas for Anticoagulant and Antidepressant Medication Use
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident receiving anticoagulant medication. Resident #5 was admitted with atrial fibrillation and had a physician order for Eliquis 5 mg by mouth twice daily. The June 2026 MAR showed the resident received Eliquis as ordered, and the quarterly MDS assessment coded the resident as moderately cognitively impaired and receiving anticoagulant medication. However, the resident’s current comprehensive care plan, last reviewed on 6/19/26, did not include a care plan focus area for anticoagulant medication use. The facility also failed to develop a person-centered comprehensive care plan for a resident receiving antidepressant medication. Resident #8 was admitted with insomnia and had a physician order for Trazodone 50 mg by mouth at bedtime. The June 2026 MAR showed the resident received Trazodone as ordered, and the quarterly MDS assessment coded the resident as cognitively intact and receiving antidepressant medication. The resident’s current comprehensive care plan, last reviewed on 6/18/26, did not include a care plan focus area for antidepressant medication use. In both cases, the MDS Nurse stated she was responsible for developing the care plans and identified the missing care plan areas as an oversight.
Failure to Update Fall Care Plan With Geri-Chair Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that included all of Resident #1’s fall interventions. Resident #1, a [AGE]-year-old female with dementia, osteoarthritis, and diabetes mellitus, had a quarterly MDS showing a BIMS score of three, indicating severe cognitive impairment, and was assessed as having falls with one fall without injury. Her comprehensive care plan identified her as being at risk for falls related to debility, advanced age, and behaviors, and included interventions such as a low bed with fall mat, tilt back wheelchair, staff education, correct positioning in chair, nonskid tape under the fall mat, use of a call light, monitoring for changes in condition, and a pommel cushion added to the chair. After Resident #1 experienced a witnessed fall from her wheelchair in the TV area, a physician order was entered for safety devices including a low bed, fall mat, and Geri-chair or tilt back wheelchair. At the time of survey observation, Resident #1 was seen in a Geri-chair in the TV area and stated she liked it and was comfortable in it. However, the care plan did not include the Geri-chair intervention. The MDS Coordinator stated she had seen Resident #1 in the Geri-chair but had not yet updated the care plan, and the DON stated whoever had the resident should have seen the order for the Geri-chair and updated the care plan.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
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