F0656

K

Failure to Develop Comprehensive Care Plans for Elopement Risk and Mechanical Lift Transfers

Enid, Oklahoma Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents identified as being at risk for elopement and for residents requiring mechanical lift assistance for transfers. For one cognitively impaired resident with a BIMS score of 2 and diagnoses including schizophreniform disorder and chronic kidney disease, two elopement risk assessments dated 08/19/25 and 11/20/25 identified the resident as a moderate elopement risk, with scores of 19 and 16 respectively. Despite these assessments, the resident’s active care plan in the current EHR did not include elopement as a focus and contained no interventions addressing elopement risk from 06/12/25 through 12/10/25. The facility’s own Elopement Management policy required updating the care plan in the EHR, and the Comprehensive Care Plans policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes based on the comprehensive assessment.

The cognitively impaired resident had a prior care plan in a previous EHR, dated 02/06/25, that included a focus on exit seeking and interventions such as analyzing key times and triggers, encouraging activities, frequent visual checks, maintaining a behavior log, and providing a pleasant home-like environment. However, this prior care plan was in an EHR that was no longer active and not accessible to staff after the facility changed systems earlier in the year. The DON acknowledged that the old focus and interventions were never carried over to the new EHR and that the care plan was not updated after the elopement assessments showed the resident was a moderate elopement risk. On 12/09/25, the resident eloped from the facility after another resident admitted to letting them out; the resident was discovered missing at 6:00 p.m., and a search was initiated with notification of family and police. The resident was later found near a church north of the building with scratches on the elbow and returned to the facility.

The deficiency also includes the facility’s failure to develop a comprehensive care plan for a resident who required assistance with transfers using a mechanical lift. This resident had intact cognition with a BIMS score of 15 and was admitted with end stage renal disease. The quarterly assessment dated 07/23/25 documented lower extremity impairments and dependence on staff for dressing, toilet hygiene, and all transfers. Despite this level of dependence, the resident’s care plan, prior to 12/22/25, did not contain any focus or interventions related to transfers or the use of a mechanical lift. On 12/16/25, during a transfer from bed to wheelchair using a mechanical lift with two aides present, the sling strap broke on one side, and the resident fell from approximately three feet, sustaining a left tibia fracture and a right clavicle fracture. The resident reported significant pain, the need for staff to feed them, embarrassment, use of a leg brace, and fear of transfers. Both the corporate nurse and the DON confirmed that residents requiring a lift to transfer should have transferring included in the care plan and that this resident’s care plan lacked any transfer-related focus or interventions prior to 12/22/25.

In addition, staff access and reliance on care planning information contributed to the deficiencies. CNA #2 stated they did not have access to the care plan and instead relied on nurses and fellow aides to learn about residents at risk for elopement and other care needs, noting that their charting system did not provide all details. This lack of direct access to care plans for direct care staff, combined with the failure to migrate or update critical care plan information in the new EHR, resulted in the absence of documented, comprehensive care plans addressing elopement risk for the cognitively impaired resident and transfer assistance for the resident dependent on a mechanical lift. The facility’s own policies requiring updated, comprehensive care plans were not followed in these instances, leading to the identified deficiencies.

Removal Plan

• Residents with an elopement score greater than 11 should have interventions in their care plan.
• The DON or designee will in-service all clinical licensed staff on completion of elopement risk assessment; staff unable to complete education will not be allowed to work until education is completed.
• An audit of all residents' elopement assessments will be completed.
• The DON or designee will update all care plans for residents identified as a moderate or high elopement risk.
• The DON or designee will monitor elopement risk assessment completion quarterly with the MDS assessment completion and update the care plans.
• The DON would track, trend, and analyze audit results and forward to the QAPI committee.