Failure to Implement Comprehensive Care Plan Leads to Resident's Unsupervised Removal
Summary
The facility failed to develop and implement a Comprehensive Person-Centered Care Plan for a resident, which resulted in an Immediate Jeopardy situation. The resident, who resided on a locked unit due to wandering behaviors, was admitted with a known protective order and an open Elderly Protective Service (EPS) case against family members. Despite these critical details, the facility did not ensure that staff were aware of the protective order or the EPS case, leading to the resident being removed from the facility by family members without supervision. The deficiency was highlighted when staff allowed two unknown family members to take the resident outside unsupervised. The staff, including a CNA and an LPN, were not informed about the protective order and EPS case, which would have prompted them to be more cautious. The resident was later found with a family member two days after being removed from the facility, indicating a significant lapse in communication and care planning. Interviews with various staff members, including the Care Manager, Social Worker, and Director of Nursing, revealed that the facility did not have a process in place to communicate critical information about protective orders and EPS cases to direct care staff. This lack of communication and failure to incorporate these details into the resident's care plan directly contributed to the resident's unsupervised removal from the facility, posing a risk to the resident's safety.
Removal Plan
- Corrective actions for the alleged deficient practice of the facility failing to ensure a comprehensive person-centered care plan to ensure nursing staff were aware of Resident #3's needs and make staff aware of Resident #3's current protective orders against 3 family members.
- All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit).
- All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned.
- All resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan.
- Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system.
- Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately.
- An immediate in-service was initiated by the Director of Nurses with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurses' station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member.
- To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress.
- The NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident.
- An Emergency QA was held with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases.
- Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination.
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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