Failure to Monitor Resident Leads to Multiple Elopements
Summary
The facility failed to implement a care plan intervention to monitor a resident routinely, which resulted in the resident eloping from the facility unsupervised on multiple occasions. The care plan did not specify the type of supervision needed or how often the resident should be monitored. This lack of specificity and monitoring led to the resident leaving the facility without staff noticing, placing the resident at risk for serious medical complications. The resident involved had a history of elopement and was diagnosed with several medical conditions, including schizophrenia, COPD, diabetes mellitus, heart failure, atrial fibrillation, and hypertension. Despite these conditions and previous elopement attempts, the facility did not adequately monitor the resident's location or behavior. The care plan interventions were vague and not individualized to the resident's needs, failing to provide clear guidance on monitoring frequency or specific supervision requirements. Interviews with facility staff revealed that the resident's location and wandering behavior were not consistently monitored or documented. The staff did not perform visual checks as required, and the resident's care plan was not updated to reflect the need for a wanderguard bracelet until after the resident's third elopement. The facility's policy and procedures for wandering and elopement were not effectively implemented, contributing to the resident's repeated unsupervised departures.
Removal Plan
- The DON contacted the physicians of residents identified for being at risk for wandering/elopement to obtain orders to monitor each resident every 2 hours. The DON contacted the physicians of the residents identified with history of elopement to obtain orders to monitor each resident every 1 hour.
- Rounding during change of shift by outgoing and oncoming nursing staff (LVN, RN, and CNA) will take place to account for all residents with emphasis on identifying the whereabouts of residents that were at risk for elopement.
- The LVN or RN will record on the Medication Administration Record (MAR) their visual check of the residents and document in the progress note the location of the residents.
- Medical Records will audit the MAR for compliance of Licensed Staff documenting on residents who have orders to monitor every 2 hours for risk for wandering/elopement and 1 hour for residents with history of elopement. The audits will be daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- Medical Records will report to the Administrator/designee the findings of the audit daily for one week, weekly for two weeks, and monthly for 3 months thereafter.
- The MDS Coordinator reviewed the care plans for the nine residents identified for being at risk for wandering to ensure residents have measurable interventions.
- Resident interventions were updated to include interventions such as but not limited to monitor residents' location every 2 hours or 1 hour, Department Managers Monday through Friday and the RN Supervisor on weekends will provide room visits daily to provide orientation for socialization and sensory stimulation and apply wander guard bracelet by Admissions or Licensed Nurse.
- Licensed staff to complete wandering/elopement assessments on admission/readmission, quarterly and when a change of condition occurs.
- The QA Nurse updates the residents special need binders/postings as residents are identified.
- The Admissions Coordinator updates the facility wanderguard binder located at each station with resident's face sheets who were identified to be at risk to elope/wander and have wander guards applied as needed.
- Wander guard binder will be checked by Admissions or QA nurse during the weekday and designated RN/LVN on the weekend.
- All residents who have been identified to be at risk for elopement/wandering will have identifiable pink color name bands.
- Residents identified to be at risk will be discussed with facility staff during daily shift huddle and weekday stand-up meetings.
- Staff will be informed of the pink color name band, special need binder/posting and wander guard binder through in-services held by the Director of Staff Development, QA nurse and/or Administrator.
- The Administrator, DON, Director of Staff Development began in servicing facility staff, which included but not limited to Nursing, Housekeeping, Maintenance, Dietary, Department Managers including front door staff and contracted rehab staff, on residents at risk for wandering/elopement and what behaviors to monitor for each resident.
- The in-service also included facility's policy and procedure titled, Wandering & Elopement and Wandering Policy.
- The in-servicing is ongoing.
- The QA nurse will audit the in-service provided to staff daily and report the findings to the Administrator.
- The Administrator will ensure all staff on assignment and currently working daily are in-serviced.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with multiple diagnoses, including diabetes and COPD, had a physician’s order for apixaban 5 mg twice daily and a corresponding care plan directing staff to administer the anticoagulant as ordered and to monitor and document specific side effects such as abnormal bleeding, bruising, black stools, pink-tinged urine, leg pain or swelling, nausea, vomiting, and sudden chest pain or shortness of breath. Record review showed no documentation that staff monitored for these anticoagulant side effects as required by the care plan, and the CNO confirmed that monitoring for the anticoagulant was not in place despite the expectation that it should have been.
A resident with paraplegia and moderate cognitive impairment, dependent on staff for transfers and using a manual wheelchair, was observed alone in a courtyard sitting in direct sunlight without a drink, contrary to his care plan interventions. The resident reported being routinely left outside unattended, without a way to call staff, and not being offered sunscreen when outside. The care plan called for encouraging fluids, supplying and assisting with sunscreen, and offering assistance in and out of doors, but an RN acknowledged there was no monitoring system or set check times while the resident was outside and that there was no physician order for sunscreen available to offer.
A resident with dementia, anxiety, repeated falls, and dependence on staff for ADLs did not have dentures and glasses addressed in the comprehensive care plan, despite documentation of very impaired cognition, communication difficulties, poor intake with chewing problems, and inconsistent eye contact. Existing nutrition and ADL care plans directed staff to assist with eating, dressing, personal care, and grooming but omitted any mention of dentures, glasses, or the resident’s preferences and responses to using them. Observations found the resident seated in a Broda chair without dentures or glasses, while staff reported these items were in the room and that the resident’s willingness to use them varied, and nursing leadership acknowledged the care plan should have reflected their use and refusals.
A resident with leukemia, dementia, anxiety, and depression was observed in bed using a transfer pole and a 1/4 bed rail, but these assistive devices were not documented in the resident’s comprehensive care plan. Record review confirmed the absence of any care plan addressing the transfer pole or 1/4 bed rail, and the CRN acknowledged that a care plan for these devices should have been in place.
A resident with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, did not have their PTSD addressed in the comprehensive person-centered care plan, despite facility policy requiring that all individual conditions and needs be reflected with measurable goals and interventions. Review of the care plan showed no focus, interventions, or tasks related to PTSD, and the CNO acknowledged that the PTSD diagnosis should have been included in the care plan but was not.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Implement Anticoagulant Monitoring Interventions in Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of a comprehensive, person-centered care plan related to anticoagulant therapy. The State Operations Manual Appendix PP requires that comprehensive care plans include specific interventions to enable residents to meet objectives, and the facility’s own policy states that care plans must include measurable goals, appropriate interventions, and realistic timeframes. Resident #2, admitted and later readmitted with multiple diagnoses including diabetes and COPD, had a physician’s order dated 12/27/25 for apixaban 5 mg by mouth twice daily. In response, the facility initiated a care plan on 12/27/25 documenting that the resident was on anticoagulant therapy and directing staff to administer the medication as ordered and to monitor and document effectiveness and potential side effects, including abnormal bleeding or bruising, black stools, pink-tinged urine, leg pain or swelling, nausea and vomiting, and sudden onset of chest pain or shortness of breath, with instructions to notify the physician as indicated. Record review showed that Resident #2’s documentation did not include evidence that staff were monitoring for the side effects of the anticoagulant as outlined in the care plan. Despite the care plan’s specific directive to monitor and document for these potential adverse effects, there was no corresponding monitoring documentation in the resident’s records. During an interview on 4/14/26 at 10:15 AM, the CNO confirmed that Resident #2 did not have monitoring in place for the anticoagulant and stated that there should have been a monitor. This lack of documented monitoring demonstrated that the facility failed to ensure that the comprehensive, person-centered care plan interventions for anticoagulant therapy were implemented for this resident.
Failure to Implement Care Plan for Resident Outside in Courtyard
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who liked to go outside in an unsecured courtyard area. During an observation, the resident was seen alone in his wheelchair in direct sunlight without a drink. In an interview shortly afterward, the resident reported that staff always left him outside unattended, that he had no way to notify staff when he was ready to return indoors, that he had not been offered sunscreen, and that he was ready to go back inside. The resident’s diagnoses included paraplegia, and his most recent Quarterly MDS showed he was moderately cognitively impaired, dependent on staff for transfers, and used a manual wheelchair for mobility. The resident’s care plan, in place since 2018, documented that he liked to go outside in an unsecured area, was not considered an elopement risk, had a BIMS score of 13, and had been educated to notify staff when outside and to remain on the sidewalk. Care plan interventions included encouraging the resident to have a drink of choice when outside, supplying sunscreen and assisting with its application when appropriate, and offering assistance in and out of doors. An RN stated there was no monitoring system or set time intervals for checking on the resident while he was outside unattended, and that staff often only told him a time limit for being outside. The RN also noted the resident was not wearing sunscreen because he often refused it previously, and the physician’s orders did not include an order for sunscreen to be available to offer. The facility’s Comprehensive Care Plan policy required periodic review and revision of care plan problems, goals, and interventions following each OBRA MDS assessment.
Failure to Include Dentures and Glasses in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s dentures and glasses. The resident had dementia with severely impaired cognition, anxiety disorder, repeated falls, and required staff assistance with oral care, toileting, bathing, dressing, footwear, and personal hygiene. The MDS and CAAs documented that the resident was very cognitively impaired, needed staff to anticipate his needs, and had communication difficulties, including missing or not understanding what was said. Existing care plans for nutrition and ADLs directed staff to provide verbal cues and assistance with eating, dressing, personal care, and grooming, but did not identify that the resident used dentures or glasses, nor did they include his preferences or responses to using these items. Facility records showed that the resident’s bottom dentures had previously broken after he placed them in his overall pocket and they fell out when staff removed his overalls. A dietitian note documented that the resident had dentures and reported difficulty chewing tougher meats, and a social services note documented that he did not always exhibit good eye contact during conversation. During observation, the resident was seated in a Broda chair near the television without his dentures or glasses and appeared restless and fidgeting. Social services staff confirmed that the dentures and glasses were in the resident’s room and that whether he wore them depended on his mood. Administrative nursing staff acknowledged that the care plan should have reflected that the resident had dentures and glasses and that he sometimes refused to wear them, but this information was not included in the care plan despite the facility’s use of the RAI process to develop individualized care plans.
Care Plan Omission for Resident Assistive Bed Devices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s comprehensive, person-centered care plan accurately reflected the use of assistive devices. One resident, admitted with multiple diagnoses including leukemia, dementia, anxiety, and depression, was observed in bed with a transfer pole on the left side of the bed and a 1/4 bed rail on the right side. Review of the resident’s care plan showed no documentation of the transfer pole or the 1/4 bed rail. In a subsequent interview, the CRN confirmed that there was no care plan implemented related to the 1/4 bed rail and transfer pole and acknowledged that there should have been. This lack of documentation and care planning for the assistive devices constituted the cited failure and had the potential to result in unmet care needs and increased risk to resident safety, as noted in the survey findings.
Failure to Care Plan for Resident’s PTSD Diagnosis
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s diagnosed Post-Traumatic Stress Disorder (PTSD). The facility’s policy on Comprehensive Care Plan and Conferences, dated 9/3/25, required that care plans reflect residents’ individual conditions, risks, needs, behaviors, cultural values, and preferences, and include measurable goals, appropriate interventions, and realistic timeframes. Resident #13 was initially admitted and later readmitted with multiple diagnoses, including chronic PTSD and joint replacement surgery aftercare, and the medical record dated 3/3/26 documented a diagnosis of chronic PTSD. However, on 3/31/26 at 2:09 PM, review of the resident’s care plan showed no focus, interventions, or tasks addressing the PTSD diagnosis. On 4/1/26 at 12:47 PM, the CNO confirmed that the resident’s PTSD diagnosis should have been care planned and had not been, demonstrating noncompliance with the facility’s care planning policy.
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