F0656

D

Failure to Update Care Plan for Wandering, Intellectual Disability, and Elopement

Garland, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all of a resident’s assessed needs, including measurable objectives and services. The resident was a 57-year-old female with diagnoses of schizoaffective disorder, diabetes mellitus, mild intellectual disability, asthma, and a history of MDRO wound infection requiring IV treatment. MDS assessments documented severe cognitive impairment with a BIMS score of 7, mood findings of sometimes socially isolating, ADL dependence requiring supervision or touching assistance, and CAAs triggered for cognitive loss/dementia, ADL functioning/rehab potential, urinary incontinence, falls, nutrition/diet, dehydration, pressure ulcers, and psychotropic drug use. The MDS also reflected evidence of mental illness and intellectual disability.

Record review showed that the resident’s care plan, dated 11/20/2025, addressed adjustment issues to admission, behavior problems related to schizoaffective disorder bipolar type, diabetes management, psychotropic medication monitoring, discharge planning, and ADL self-care performance deficits. Interventions included monitoring behavior episodes, documenting behaviors and interventions, approaching the resident calmly, talking during care, allowing time for responses, and not rushing care. However, despite the resident’s diagnoses and cognitive status, the care plan did not include specific problems, goals, or interventions related to her wandering behavior, her intellectual disability, or her most recent elopement incident on 01/05/2026.

Care plan conference notes dated 01/09/2026 documented an interdisciplinary meeting with the DON, SW, DOR, DM, AD, Administrator, and the resident’s representative (RP), during which the RP expressed concerns about placement and safety, stated the resident was not believed to be exit seeking and had no history of elopement, and requested that the resident not be “locked up like a prisoner.” The RP indicated willingness for the facility to determine what was best, agreed the resident could be moved to memory care if an unlocked unit did not work, and reported the resident had issues regulating and consistently taking medications. The RP also stated that at the previous placement the resident had been on a locked memory unit with door alarms, believed facility door alarms would alert staff to exits, and stated the resident will wander off and should not have been allowed to go alone to a hospital appointment on 01/05/2026. Interviews with the MDSC and DON confirmed that MDS nurses and nursing staff were responsible for updating care plans with changes, and that if not updated, the care plan would not reflect current treatments and care needs. Despite this, the resident’s care plan remained without entries addressing wandering, intellectual disability, or the recent elopement incident.