F0656

D

Failure to Maintain Comprehensive Care Plan for Dementia and Elopement Risk

Dallas, Texas Survey Completed on 02-06-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s medical, nursing, mental, and psychosocial needs, specifically related to dementia and elopement risk. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and his admission MDS documented non-Alzheimer’s dementia and a BIMS score indicating intact cognition at that time. Despite this, on a later date the Resident Assessment Coordinator (RNC) struck out dementia as a primary diagnosis from the medical record and it no longer appeared on the face sheet, based on the resident’s high BIMS score and nursing assessments, without documenting the rationale or the conversation with the MD. The MD confirmed he discontinued the dementia diagnosis after being informed of the BIMS score, and he was not aware of the resident’s exit-seeking or elopement behaviors.

The resident’s care plan initially included problems for impaired cognitive function/dementia, use of psychotropic medication (Donepezil) for dementia, and risk for elopement related to an elopement evaluation risk score. However, the most recent care plan revision did not include the resident’s elopement attempt and actual elopements that occurred on multiple dates. Instead, the revised care plan described the resident as a potential safety risk when leaving the facility, referenced his history of leaving facilities independently, and emphasized his autonomy and independent decision-making, citing a BIMS score of 13 and his pattern of self-checking into hospitals. The care plan continued to list impaired cognitive function/dementia and dementia medication, even though the dementia diagnosis had been removed from the medical record, and it did not incorporate the documented episodes of exit-seeking, aggression, and involvement of police.

Elopement risk evaluations for the resident were inconsistently completed and contained discrepancies. An evaluation on one date identified the resident as a moderate elopement risk, cognitively impaired and able to ambulate or propel himself, while later evaluations marked him as no risk and either unable or able to make decisions and ambulate, with only the “No Risk” section completed. Questions that would have evaluated him as moderate or imminent risk were triggered but left incomplete, preventing the electronic system from classifying him appropriately. Progress notes documented that security called nursing when the resident attempted to leave through the gate, that he had two episodes of elopement with aggressive behavior and statements about wanting to leave, and that he later left the facility and independently checked into a local hospital. Staff interviews confirmed awareness of his unsafe status to be out alone and acknowledged that care plans are the guide for care and must be updated with changes in condition, yet the resident’s care plan was not revised to reflect his dementia diagnosis status, his ongoing dementia medication, or his repeated elopement attempts and actual elopements.

Facility policy required the IDT to develop a culturally competent, trauma-informed, comprehensive person-centered care plan with measurable objectives and timetables, to be completed and periodically reviewed and revised with each assessment and with changes in condition, behavior, or care. The policy also specified that the care plan must describe services to meet the resident’s highest practicable well-being and be revised for changes in behavior and care. Interviews with the DON and Administrator confirmed that admitting nurses initiate care plans, the MDS nurse and nursing leadership are responsible for updates, and that failure to keep care plans current poses a risk because staff may miss needed care. Despite these requirements and acknowledgments, the resident’s care plan and elopement risk tools were not accurately or fully updated to reflect his dementia-related diagnosis history, his use of dementia medication, and his documented exit-seeking and elopement events.