§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on clinical record reviews, and interviews with staff, it was determined the facility failed to implement interventions following prior elopement behavior and failed to revise the care plan to reflect newly identified elopement risk and escalating behavioral for one of one resident reviewed. (Resident R1)
Findings include:
Review of the facility's undatedLeave of Absence (LOA) Policy indicated that a Leave of Absence is a temporary period when a resident leaves the facility with the expectation of returning. The policy requires staff to ensure the resident is clinically stable prior to departure, obtain a signed LOA form, document the date and time of departure, and provide any necessary instructions. Upon the resident's return, staff are required to document the time of return, complete a nursing assessment, and update the care plan if indicated. The policy also states that if a resident does not return as expected, staff must attempt to contact the responsible party and take additional steps, including notifying authorities if the resident's safety cannot be confirmed.
Review of Resident R1's Minimum Data Set (MDS- a federally required assessment) dated January 10, 2026, revealed the resident was admitted on December 17, 2025. The resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The assessment indicated the resident required partial to moderate assistance with sit-to-stand, chair-to-bed transfers, toilet transfers, and ambulation of 10 and 50 feet with turns, and was totally dependent for car transfers.
Resident R1's diagnoses included coronary artery disease (narrowing of the arteries that supply blood to the heart), hypertension (high blood pressure), diabetes mellitus (a disorder affecting blood sugar regulation), cerebrovascular accident (CVA), also known as a stroke caused by interrupted blood flow to the brain, malnutrition (inadequate intake of nutrients needed for health), generalized weakness (reduced muscle strength affecting mobility), and a history of falls. The resident's medication regimen included antiplatelet medications (to prevent blood clots), hypoglycemic agents including insulin (to control blood glucose), and anticoagulant therapy (blood thinners used to prevent clot formation).
Review of Resident R1's nursing notes revealed that on January 12, 2026 at 3:27 PM, Resident R1 was involved in a verbal altercation with another resident. During the incident, the other resident ran toward Resident R1 and punched the resident. No visible injuries were noted for either resident. The Director of Nursing (DON), physician, police, and the responsible party were notified of the incident.
Continue review of nursing notes revealed that on January 13, 2026 at 9:52 AM, Resident R1 was transferred to room to another room. Within five minutes, the resident was involved in a verbal altercation with his new roommate. As a result, the resident was subsequently transferred to a different nursing unit.
Nursing note dated January 20, 2026, at 9:23 AM, state that the facility contacted the emergency room (ER) and was informed that Resident had left the ER without being seen at 7:00 AM. The resident returned to the facility at 9:00 AM. A new elopement assessment was completed, and the resident was identified as a flight risk. The physician, Social Services, and Administration were notified, and a full body assessment was completed with no skin issues noted.
Review of Resident R1's elopement risk evaluation dated January 20, 2026, revealed that the resident is at risk for elopement, with a score of 2.0. The evaluation was based on several factors, including a history of attempting to leave the facility without informing staff, wandering behavior, and behavior that could compromise the safety or well-being of self or others. Additionally, the resident had been recently admitted within the past 30 days and had not fully adjusted to the facility. According to facility protocol, a score greater than 1 indicates that the resident is considered at risk for elopement.
Review of nursing note dated January 30, 2026 at 2:25 PM, revealed the resident was found smoking in his room. Social Services was notified, and the resident verbally threatened another resident , stating he would beat him up.
Continued review of nursing notes revealed a note dated February 4/2026 at 11:36 PM, the resident remained on a Leave of Absence (LOA). A phone call was placed to follow up, but there was no answer. A message was left for the responsible party.
Review of Resident R1's care plan revealed multiple identified risk areas beginning December 17, 2025, including risk for impaired skin integrity, self-care deficits with expected ADL decline, risk for adverse medication reactions related to medication use, and discharge planning needs. Discharge planning was initiated upon admission, with goals to provide community resource information and ensure appropriate support systems are in place prior to discharge.
The care plan further identifies diabetes management goals to prevent complications, continued monitoring for medication-related adverse effects, and fall risk with interventions to anticipate and meet resident needs. Additional problem areas include potential oral/dental health issues and nutritional concerns related to abnormal labs, heart disease, diabetes, and a history of high added-sugar dietary patterns.
Behavioral concerns were added to the care plan on January 12, 2026, following an incident in which the resident punched another resident. The care plan reflects potential for physical and verbal aggression, as well as smoking-related behaviors. On February 4, 2026, a self-determination focus was added addressing the resident's choice not to follow facility smoking rules, with a goal for the resident to discuss and understand the potential negative consequences of noncompliance.
Continue review of Resident R1's care plan revealed that there was no care plan developed for wandering behaviors or elopement risk.
Interview with Social Worker, Employee E3 on February 26, 2026 at 08:58 a.m. confirmed she was familiar with the resident and spoke with the resident on January 20, 2026 regarding the facility's Leave of Absence (LOA) policy. She informed the resident that he could not go out that day because the physician was not available to provide consent. Employee E3 described the resident as someone who frequently expressed a desire to leave the facility. At the time of that discussion, she stated she was unaware that the resident had been identified as an elopement risk. She further indicated she was not aware that the care plan had been updated to reflect elopement risk status.
28 Pa. Code 201.18(b) Management
28 Pa. Code 211.12(c)(d)(5) Nursing Services
| | Plan of Correction - To be completed: 03/26/2026
F657
Resident R1 is no longer residing at Independence Rehab and Nursing.
DON or designee will review all residents identified by assessments with risk of elopement. Resident identified as at risk are not to leave out on LOA, unless deemed safe by Medical Director. This will be communicated to both nursing, social services, as well as all receptionists.
The 3 departments mentioned above will be reeducated on LOA policy specifically regarding residents identified with positive risk for elopement.
Weekly audits will be conducted by DON or designee to ensure LOA/ elopement risk policy is being followed. Audits will be weekly x4 followed by monthly x3 months.
Results of these audits will be reported to monthly QAPI meeting.
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