F0656

D

Failure to Care Plan and Implement Escort Needs for Cognitively Impaired Resident

Houston, Texas Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident’s need for an escort to off-site medical appointments. The resident was an older male with multiple significant diagnoses, including unspecified dementia with agitation, hypertension, dysphagia, hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, depression, HIV disease, cognitive communication deficit, and blindness in one eye. His Annual MDS showed he was rarely or never understood, had short- and long-term memory problems, was severely impaired in daily decision-making, and was totally dependent on staff for toileting, showering, footwear, and bed mobility. Despite these documented cognitive and functional impairments, his care plan did not include an intervention or measurable objective related to the need for an escort to accompany him to medical appointments.

The resident’s care plan, dated in early January, addressed ADL self-care deficits, impaired cognitive function/dementia, and seizure disorder, with interventions such as total staff assistance for bathing and transfers, cuing and reorientation, consistent routines and caregivers, and seizure management steps. However, there was no care plan problem, goal, or intervention addressing the resident’s inability to communicate effectively or manage his own medical information during off-site visits, nor any directive that he required an escort. A care plan meeting held shortly before the survey documented that the responsible party (RP) attended and that no concerns, issues, or changes from the last care plan were recorded, despite the resident’s significant cognitive and communication deficits. The medical record also lacked documentation of the resident’s clinic visit that occurred at the end of December, with no progress notes, assessments, or uploaded records related to that appointment.

Interviews and observations further demonstrated that the resident’s need for an escort was not incorporated into his care plan or consistently implemented. Clinic staff reported that when the resident arrived for his appointment, he seemed “out of it” and did not have his health information with him, and that the NP had to call the RP, who stated that facility staff should have gone with him. The RP stated she was aware of the appointment and that the facility told her they would get him to the appointment, but did not tell her she needed to attend; she also stated the resident was unable to talk about what was going on with him and that she had brought this to the facility’s attention during a care plan meeting. Facility staff, including an LVN, the SW, the MDS nurse, the DON, and the Administrator, gave varying accounts about who usually accompanied the resident and acknowledged there was no specific policy and no documentation in the record indicating that an escort was required. The SW admitted she forgot to update the record to indicate the need for an escort, and the MDS nurse acknowledged that, given the resident’s BIMS of 00 and that he was rarely or never understood, he should have been accompanied. The Administrator stated there was a communication breakdown and that having an escort should have been documented in the resident’s record, but it was not, and no notes from the clinic visit were available in the record as of survey exit.

The facility’s failure to include the need for an escort in the resident’s comprehensive care plan, despite his severe cognitive and communication deficits and total dependence on staff, and the absence of documentation of the off-site clinic visit, constituted a failure to ensure a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the resident’s identified medical, nursing, and psychosocial needs. The report states that this failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.