Failure to Update Care Plan After Repeated Elopement and Behavioral Incidents
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Update Care Plans for Comfort Care and Pressure Ulcers: The facility did not revise the care plan for a resident placed on comfort care after a clinic visit showed worsening fluid retention, cough, swelling, and decreased strength; the plan omitted the no-hospitalization order, discontinuation of labs, and guidance for comfort if the resident declined. The facility also failed to update another resident’s care plan after the MDS identified four Stage II pressure ulcers, leaving only general skin-risk interventions instead of wound-specific goals and treatment measures.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Care plans and related care guides were not updated for a resident with pain, a resident with recurrent falls, and a resident with severe cognitive impairment and transfer needs. One resident’s plan lacked individualized nonpharmacological pain interventions, another resident’s plan omitted a motion sensor that staff were using for fall prevention, and a third resident’s plan and Kardex incorrectly stated the resident was independent with transfers despite staff using a transfer belt and Hoyer lift with two-person assistance.
Failure to revise care plans for two residents left key safety and behavior needs undocumented. One resident with dementia had scissors removed after cutting clothing and hair, but the care plan did not include supervised scissor use. Another resident with a wander guard repeatedly wanted to go outside and attempted to go out on his own, but the care plan did not identify elopement risk or specific interventions for staff. Interviews confirmed staff knew about both residents’ needs, yet the care plans did not reflect those changes.
Failure to update care plan after change in condition: A resident was hospitalized with acute urinary retention and constipation related to neurogenic bowel, but the care plan was not revised to reflect the new diagnosis or related interventions. The MDS Director and MDS Coordinator stated they were unaware of the hospital transfer and acknowledged the care plan should have been updated to support coordinated, individualized care.
A resident with a history of anemia, moderate dementia, and chronic pain had active orders for aspirin for CAD and sertraline (Zoloft) for depression and chronic pain, but the comprehensive care plan was not revised to reflect current diagnoses and medication indications. The care plan continued to reference anemia and daily aspirin for antiplatelet therapy and included a directive to administer antidepressants for chronic pain without specifying sertraline’s use for both depression and chronic pain. An MDS nurse acknowledged that the resident no longer had an active anemia diagnosis and that the care plan should have been updated to clarify the current clinical rationale for aspirin therapy and the indication for sertraline.
Failure to Update Care Plans for Comfort Care and Pressure Ulcers
Penalty
Summary
The facility failed to revise the care plan for a resident who was changed to comfort care only after a clinic visit identified worsening fluid retention, weight gain, generalized swelling, decreased strength, occasional shortness of breath, and a persistent cough. The physician ordered that the resident not be hospitalized, that metolazone be stopped, Lasix be increased to 80 mg twice daily, and that labs be discontinued per family request. The current care plan addressed diuretic therapy and a goal for the resident to be free of discomfort, but it did not include the comfort care status, the order not to hospitalize, the discontinuation of lab draws, or instructions for maintaining comfort if the resident’s condition worsened. Nursing notes showed the resident remained in her room in a recliner and was heard coughing continuously, with the cough worsening. Staff administered PRN morphine for chronic cough related to fluid overload, but it was ineffective and the resident reported severe pain and no relief from the cough and discomfort. Additional notes documented continued coughing, shortness of breath, and little relief after cough syrup and morphine were given. The DON acknowledged the care plan should have been revised to identify what staff were to do to provide comfort if the resident’s condition worsened. The facility also failed to revise the care plan for another resident who developed pressure ulcers. The resident’s comprehensive MDS identified four Stage II pressure ulcers, and the CAA directed staff to address the wounds on the care plan with daily treatment, weekly and as-needed monitoring, physician notification for decline or signs of infection, and goals to slow or minimize decline and provide symptom relief or palliative measures. However, the current care plan only identified the resident as at risk for skin integrity impairment and included general measures such as nutrition, moisture control, skin care, and barrier cream use; it did not identify the actual pressure ulcers or include interventions to promote healing or reduce infection or discomfort. The MDS nurse stated she missed revising the care plan to include the pressure ulcers, and the DON stated it was her expectation that a pressure ulcer be identified on the care plan with appropriate goals and interventions.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Care plans not updated for pain interventions, fall precautions, and transfer needs
Penalty
Summary
The facility failed to update care plans and related care guides to reflect current, individualized interventions for three residents. For one resident with quadriplegia related to a spinal injury and ongoing pain, the admission MDS showed intact cognition, scheduled pain medication, and no non-medication pain interventions. The resident stated he had a lot of pain and had been seen by a pain doctor, but the care plan only listed general pain management and comfort measures without identifying the resident’s preferences for nonpharmacological interventions or documenting whether any had been attempted, effective, ineffective, or preferred. The MAR/TAR and progress notes also lacked identification of nonpharmacological pain interventions. For another resident with moderately impaired cognition and a history of multiple falls, the quarterly MDS documented two or more falls with no injury and one fall with nonmajor injury. The care plan included several fall precautions such as frequent safety checks, a low bed, a floor mat, and non-slip footwear, but it did not include the motion sensor with automated auditory reminders that staff were using. Staff observed the resident with the motion sensor in place, and nursing staff stated the device had been used since after a fall in November 2025. The care plan did not identify when the motion sensor should be used or what adverse effects should be monitored. For a third resident with severe cognitive impairment, delusions, behavioral symptoms, and diagnoses including dementia with behavioral disturbances, anxiety, affective disorder, diabetes, and hearing loss, the care plan and Kardex stated the resident was independent with transfers. However, staff observed the resident being transferred with a transfer belt, requiring assistance from two nursing assistants, and later being moved to and from twin mattresses placed on the floor using a Hoyer lift with two staff. Staff confirmed the resident was not independent with transfers and that the care plan and Kardex had not been revised to reflect the resident’s current transfer ability or the use of the Hoyer lift and mattresses on the floor.
Failure to Revise Care Plans for Safety and Elopement Needs
Penalty
Summary
The facility failed to revise the care plan for 2 of 12 sampled residents, R15 and R18, after changes in condition and identified needs were documented. The report states the care plan was not updated within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by a team of health professionals as required. Review of the records and interviews showed that the existing care plans did not reflect the residents’ current assessed needs and behaviors. For R15, the 4/6/26 quarterly MDS showed severely impaired cognition, with independence in dressing, toileting, and ambulation using a walker, and diagnoses including Alzheimer’s disease, dementia, muscle weakness, hallucinations, anxiety disorder, and long-term pain medication use. On 5/4/26, R15 stated the facility had taken away her scissors and she could no longer use them for knitting, while a bag of yarn and string was observed near her recliner. A 4/15/26 progress note documented housekeeping staff reported R15 had been cutting her clothes and had cut her hair, and social services noted a plan for supervised scissor use. R15’s care plan addressed leisure preferences and one-to-one interactions, but it did not include supervised assistance with scissors for safety reasons. The IDON confirmed R15 had been cutting her clothing and hair, was not safe to use scissors unsupervised, and that the care plan should reflect that need. For R18, the 5/6/26 quarterly MDS showed a BIMS score of 13, indicating cognition intact, with independence in dressing, toileting, and ambulation using a walker, wandering noted during the assessment period, and use of oxygen and multiple medications including antipsychotic, antidepressant, hypnotic, anticonvulsant, pain, and antiplatelet drugs. On 5/4/26, R18 stated he had an alarm on, wanted to go outside, and believed it was illegal that he could not go out by himself; he also said staff told him he needed someone to go outside with him but there was never anyone available. His care plan noted cognition-related needs and a wander guard, but it did not identify elopement risk, a goal, or interventions for what staff should do if he attempted to leave or when he wanted to go outside. The elopement evaluation left the risk for wandering and/or elopement blank, and interviews confirmed staff knew he wanted to go outside, sometimes attempted to go out on his own, and that the care plan lacked detailed interventions.
Failure to Update Care Plan After Hospitalization
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #38 to reflect a significant change in condition after the resident was diagnosed in the hospital with acute urinary retention and constipation related to neurogenic bowel. A review of the resident’s hospital record showed this diagnosis on 04/21/2026 at 12:05 AM, but none of the resident’s care plans reflected the new condition or related needs. During an interview on 04/27/2026, Resident #38 stated that episodes of constipation had previously led to urinary retention requiring self-catheterization. On 04/30/2026, the MDS Director and MDS Coordinator stated that care plans were revised after hospitalizations and with changes in condition, but they were not aware the resident had been transferred to the hospital. They acknowledged that the care plan should have been updated to include the resident’s new diagnosis and appropriate interventions and monitoring, and the facility policy stated that care plans are revised as residents’ information and condition change.
Failure to Update Care Plan With Current Diagnoses and Medication Indications
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect accurate and current information for one resident. The resident was admitted with multiple diagnoses including anemia, moderate dementia, and chronic pain, and had physician orders for aspirin 81 mg daily for CAD and sertraline (Zoloft) 50 mg daily for depression and chronic pain. The comprehensive care plan continued to list a problem statement indicating a history of anemia with a requirement for daily aspirin for antiplatelet therapy, initiated several years earlier, and included a directive for licensed nursing staff to administer antidepressants for chronic pain. However, the care plan was not updated to specify that sertraline was being administered for both depression and chronic pain, and it was not revised to reflect that the resident no longer had an active diagnosis of anemia or to clarify the current clinical rationale for aspirin therapy. During an interview, the MDS nurse acknowledged that the care plan should have been revised to accurately reflect the resident’s current diagnoses and medication indications. This failure created the potential for inaccurate care planning and inconsistent implementation of care, as the written care plan did not align with the resident’s current clinical status and medication orders as identified through record review and staff interview.
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