Failure to Review and Revise Care Plans for Behavioral and Elopement Risks
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were reviewed and revised to address the changing needs of two residents. For one resident with diagnoses including unspecified dementia, schizoaffective disorder, and anxiety disorder, the care plan addressing behavior problems such as screaming, yelling, and cursing was last reviewed in May 2022. Despite multiple documented behavioral incidents between May and June 2025, there was no evidence that the care plan was updated to reflect these ongoing behaviors. Interviews with staff confirmed that the resident continued to display these behaviors and that the care plan had not been reviewed as required. Another resident, admitted with multiple diagnoses including non-Alzheimer's dementia and psychotic disorder, was identified as having severe cognitive impairment and was at risk for elopement, with a wander guard in place. The care plan for elopement risk and wandering was last reviewed in October 2024, despite ongoing documentation of wandering behaviors and quarterly assessments. Staff interviews revealed that while general notes were made in the resident's progress notes, the care plan itself was not updated to reflect the resident's current status or behaviors. Facility policy requires that care plans be reviewed at least quarterly and revised as changes in the resident's condition dictate. However, in both cases, there was no documented evidence that the care plans were reviewed or revised in accordance with policy or regulatory requirements, despite clear indications of changes in the residents' behaviors and needs.