Failure to Follow Care Plan for Side Rail Use
Summary
A deficiency was identified when staff failed to implement a patient's care plan as ordered. The patient, who was legally blind, dependent on staff for activities of daily living, and at high risk for falls, had a care plan and physician order specifying that one fourth side rails should be up while in bed to assist with positioning and turning. During an observation, the patient was found lying in bed with the bed in the highest position and the left one fourth side rail down, contrary to the care plan and physician order. Certified Nursing Assistant 2 confirmed that the side rail should have been up and that the patient required it for mobility and fall prevention. Further interviews with nursing staff confirmed that beds should not be left in a high position unattended and that the care plan required the side rail to be up while the patient was in bed. Review of facility policy indicated that comprehensive care plans with patient-specific interventions must be implemented. The failure to follow the care plan and physician order for side rail use constituted the deficiency.
Plan Of Correction
C835: T22 DIV5 CH3 ART3- 72311(a)(2) Nursing Service - General Corrective action for resident found to have been affected by this deficiency: On 3/10/2025, both rails were verified to be up by DSD for resident 5. Identify any other residents who may have been affected by the deficient practice: On 3/10/25, ADONS and DSD performed rounds of the entire facility to ensure that any patients who had orders for side rails were following MD orders and adhering to the care plan. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur: Beginning 3/10/2025, DSD initiated in-servicing of CNA and licensed nursing staff regarding ensuring side rails are being utilized in accordance with physician's orders and patient plan of care. (To continue page 3 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: Beginning 3/10/25, DSDS will perform weekly rounds of all in-house patients to ensure that if side rails are ordered, they are in place as per MD orders and plan of care. These audits will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25
Penalty
A resident with dementia and a traumatic brain injury, identified as being at risk for elopement, was able to leave the facility unsupervised and undetected for about an hour. The resident's care plan and assessments documented the need for supervision due to cognitive impairment and a history of wandering, but staff did not implement the required supervision as outlined.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a traumatic brain injury from eloping from the facility. The resident was identified as being at risk for elopement based on an Elopement Evaluation and had a care plan in place that addressed this risk, including a history of wandering and previous elopement at a hospital. The resident's Minimum Data Set assessment indicated impaired cognitive status, and the care plan specifically noted the need for supervision due to alcohol/drug-seeking behavior and elopement risk. Despite these documented risks and care plan interventions, the resident was able to leave the facility unsupervised and undetected. Staff became aware of the resident's absence after being informed by another staff member, and the resident was missing for approximately one hour before being located. Facility policy required adequate supervision for residents at risk of elopement, but this was not implemented as indicated in the resident's care plan. Interviews with facility staff and the administrator confirmed the resident's high risk for elopement and acknowledged that closer supervision should have been provided.
Plan Of Correction
The preparation and/or the execution of this plan of correction do not constitute admission of agreement by the provider of true facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because the provisions of the Federal and State law require it. This Plan of Correction constitutes the facility's credible allegation of compliance. Corrective action accomplished for identified resident(s) affected by the deficient practice: Resident 1 was found and brought back into the facility without incident or injury. Resident placed on 1 on 1 supervision until the wanderguard system for the front door was adjusted with an additional reader on 10/3/2025. How other residents having potential to be affected by the same deficient practice will be identified and what corrective action will be taken: On 10/2/2025, an audit of all residents that triggered at risk for elopement was completed by the Medical Records Director to ensure that they all have appropriate interventions in place. Updates made as identified. Immediate measures and systemic changes put in place to ensure that the deficient practice does not recur: On 10/1/2025 and 10/2/2025, the Director of Staff Development in-serviced CNAs and Licensed Nurses on the elopement policy and procedure and wanderguard devices. A description of the plans and persons responsible for monitoring ongoing performance, and ensuring that the corrective actions are achieved and sustained: The Medical Records Director or designee will conduct an audit for residents triggering as elopement risks weekly to confirm interventions are in place. The results of the audits will be reported to the QAPI Committee meeting monthly for 3 months and then re-evaluated thereafter. Completion Date: 11/4/2025
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.