F0657

D

Failure to Update Care Plan After Repeated Elopement and Behavioral Incidents

Phoenix, Arizona Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to review and update a resident’s comprehensive care plan after multiple elopement and behavioral incidents. The resident had vascular dementia, mood disorder, constipation, venous thrombosis and embolism, hypotension, dysphagia, anxiety disorder, and post-traumatic stress disorder. A quarterly MDS showed severely impaired cognitive skills for daily decision-making and no BIMS assessment. The existing care plan, dated June 9, 2025, identified the resident as at risk for elopement related to a history of elopement before admission and during the stay, with interventions such as assessing for fall risk, monitoring for fatigue and weight loss, and residing on a secure unit. A behavioral treatment care plan dated November 24, 2025, addressed sundowning behaviors with interventions including reassurance, a structured and soothing environment, reduced stimulation before sundown, a consistent evening routine, calming activities, gentle redirection, and monitoring for physical needs.

On December 4, 2025, an incident occurred in which the resident was pacing in the hallway, appeared restless, and then ambulated toward a north exit door, exiting into the smoking area. Staff followed immediately and observed the resident climbing a wall. Verbal redirection was attempted but was not effective, and a facility code was initiated. One nurse positioned outside the wall while additional staff remained inside with the resident. The resident jumped over the wall to the outside area and began running off facility grounds. Staff continued attempts to redirect the resident back to safety but were unsuccessful. The resident was ultimately returned with assistance from 911 and sent to the hospital for evaluation, with no injuries noted. Despite this elopement event, review of the care plan showed no updated care plan or new interventions for the elopement risk focus area, and no evidence that the behavioral care plan was updated after this incident.

A second incident on December 7, 2025, documented that the resident was restless, agitated, and pacing in the hallway, refusing all medications, treatments, and vital signs. The resident entered other residents’ rooms, entered the nurses’ station, went through drawers, and called 911 multiple times. Redirection and distraction were unsuccessful, and after the police arrived, the resident exited the unit and the facility. Staff called 911, and the ADON was notified. The resident was observed with a large rock, posturing and attempting to throw it at staff, then climbing a brick wall with the rock in hand and proceeding toward the street. The nurse and another staff member remained present, and with the arrival of the ADON and police, the resident was helped back to the facility. A scrape on the left wrist was noted, and a psych provider ordered psychiatric evaluation and stabilization at a medical center. Review of the care plan again revealed no updated care plan or new interventions for elopement risk after this second incident, and no updates to the behavioral care plan or elopement care plan were found.

A discharge summary later documented that the resident made his way outside by holding the exit door onto the patio, climbed over the fence, and jumped, with uncertainty about whether he hit his head. Staff went outside and called 911 for assistance; the resident returned inside the facility and later exited the patio again, leading to a call to AMR for assessment as directed by the DON. Interviews with staff showed that a CNA recognized elopement risk by resident behaviors such as wandering and stated that interventions included close observation, redirection, and monitoring movements, but also stated she did not handle care plans or know what new interventions would be placed after the resident left the facility. An LPN stated that nurses do not create care plans and that the ADON and DON update care plans and add interventions, and that she could only suggest interventions. The DON stated that the resident had climbed the fence three times, that the resident was sent to the hospital after the first and second incidents and seen by a psych provider, and that these actions were not reflected in the care plan. The DON acknowledged that no new interventions or medication changes were placed when the resident returned and that interventions should have been implemented in the care plan but were not, and that failure to update the care plan can risk a resident not getting proper care. The facility’s care plan policy required the interdisciplinary team to review and update the care plan when there has been a significant change in the resident’s condition or when desired outcomes are not met, which did not occur in this case.