BATON ROUGE, LA - A February 2025 federal inspection at Heritage Manor of Baton Rouge II revealed systemic failures in resident supervision that allowed a dementia patient with an active protective order to be removed from the facility, resulting in an immediate jeopardy citation—the most serious deficiency level issued by federal regulators.
Vulnerable Resident Left Facility Despite Multiple Risk Factors
The inspection, completed on February 21, 2025, documented a case involving a resident identified as Resident #3, who was admitted with multiple serious cognitive conditions including dementia, encephalopathy, and altered mental status. The resident's medical history and social circumstances made her particularly vulnerable: hospital discharge records indicated "housing instability" and noted that Elderly Protective Services (EPS) had an open case involving multiple family members.
According to the inspection report, a protective order had been filed against the resident's Responsible Party on January 13, 2025, remaining effective through February 26, 2025, due to documented domestic abuse concerns. The local hospital's discharge summary from January 31, 2025, explicitly noted that "EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation."
Despite this complex and potentially dangerous family dynamic, the facility failed to implement adequate safeguards. On February 8, 2025, the resident left the facility and did not return. Staff subsequently contacted Elderly Protective Services to report that "the resident's family removed her from the facility"—a deeply concerning outcome given the existing protective order and EPS involvement.
Critical Documentation Failures Compounded Risk
The inspection revealed a troubling pattern of documentation errors that directly contributed to the resident's inadequate supervision. Federal surveyors examined the facility's Nurse Data Collection and Screening form dated February 6, 2025, and found a significant inconsistency in the elopement risk assessment.
Questions 1 through 3 on the screening tool were all answered "yes," indicating the presence of multiple elopement risk factors. The form's instructions explicitly stated that if any of questions 1 through 5 were answered affirmatively, the resident should be considered at risk for elopement. However, Question 6—which directly asked whether the resident was at risk for elopement—was marked "No."
This contradictory documentation meant that despite meeting the facility's own criteria for elopement risk, the resident was not properly classified as at-risk in official records. The screening also failed to document that the resident was using a wander guard device, even though a separate care plan document indicated one had been ordered for her right ankle on February 4, 2025.
When surveyors reviewed the facility's Wanderers' Binder at the nurse's station—the primary reference tool staff use to identify residents requiring enhanced supervision—they found a wander guard list dated January 31, 2025. The accompanying list of elopement risk residents did not include Resident #3.
Why Elopement Protocols Matter for Dementia Patients
The failures documented at Heritage Manor represent serious safety concerns for individuals with cognitive impairment. Dementia affects approximately 6.7 million Americans aged 65 and older, and wandering behavior is one of the most dangerous symptoms associated with the condition. Research indicates that up to 60% of individuals with dementia will wander at some point during their illness.
For patients with encephalopathy—a condition involving brain dysfunction that affects cognition and behavior—the risks are compounded. These individuals often experience confusion, disorientation, and impaired judgment that makes them incapable of protecting themselves in unfamiliar environments. The combination of dementia and encephalopathy documented in Resident #3's case represents a particularly high-risk profile requiring vigilant supervision.
When residents with cognitive impairment leave a facility without appropriate supervision, the consequences can be severe. Exposure to weather extremes, traffic hazards, dehydration, and physical injury are immediate concerns. For residents with complex family situations involving protective orders, as in this case, the risks extend to potential exposure to individuals from whom they have been legally ordered to be protected.
Federal regulations require nursing homes to provide adequate supervision to prevent accidents based on each resident's individual risk factors. This includes maintaining current assessments of wandering and elopement risk, implementing appropriate interventions, and ensuring staff have access to accurate information about which residents require enhanced monitoring.
Care Plan Deficiencies Left Staff Uninformed
The resident's Comprehensive Plan of Care, initiated on February 3, 2025, did acknowledge her impaired thought process and elopement risk. The plan included interventions to "cue, reorient, and supervise as needed" and documented the wander guard order from February 4, 2025.
However, surveyors noted a critical gap: the care plan "failed to reveal interventions to ensure staff were aware of Resident #3's current protective order and open Elderly Protective Services (EPS) case against three family members."
This omission is significant because nursing home staff interact with family members regularly. Without explicit documentation and communication protocols regarding protective orders, staff members would have no mechanism to recognize that certain individuals should not have access to the resident or be involved in decisions about her care and placement.
A progress note from February 4, 2025, at 3:01 p.m., documented that staff "notified Resident #3's Responsible Party" that the resident would be placed on the memory care unit due to wandering. This communication was made to the very individual against whom a protective order had been filed—illustrating exactly the type of situation that should have been prevented through proper care planning and staff notification protocols.
Facility's Elopement Policy vs. Practice
Heritage Manor's written policy on Elopement/Wandering, revised in January 2023, outlined clear expectations for identifying and monitoring at-risk residents. The policy defined elopement as occurring "when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so."
The policy required that all residents be "observed and evaluated for demonstration of elopement risk" using specific screening tools on admission and during each Minimum Data Set assessment period. It also mandated that "a list of residents shall be available at the nurse's stations with residents at risk for wandering indicated" and that "orientation of all staff to potential wanderers will be performed on an ongoing basis."
The inspection findings demonstrate that while these policies existed on paper, their implementation was inconsistent. The screening tool was completed incorrectly, the wanderer list was outdated and incomplete, and critical information about the protective order was not communicated to staff through the care plan—all direct violations of the facility's own stated procedures.
Immediate Jeopardy Citation and Corrective Actions
Federal surveyors classified this deficiency as causing "immediate jeopardy to resident health or safety"—the highest level of severity in the federal enforcement system. This classification indicates that the facility's failures created conditions that were likely to cause serious injury, harm, or death to residents.
Following the incident, the facility implemented corrective actions beginning February 20, 2025. According to the inspection report, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) audited all resident electronic charts and hard copy charts to determine whether any other residents had protective orders in place. The audit, completed at 7:50 p.m. on February 20, 2025, identified no additional residents with protective orders.
On February 21, 2025, the facility's DON, ADON, and MDS Nurses conducted additional audits of all residents considered an elopement risk "to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan."
The inspection identified 34 residents as potentially affected by the deficient practice: two residents with secure care bracelets and 32 residents on the secure care unit. For these individuals, accurate elopement risk assessment and proper communication of relevant safety information is essential to prevent similar incidents.
Additional Issues Identified
Beyond the primary elopement violation, the inspection cited the facility under F609, which addresses reporting requirements. Federal regulations require nursing facilities to report allegations of abuse, neglect, and exploitation to appropriate authorities within specific timeframes. The circumstances surrounding Resident #3's departure from the facility—particularly given the active protective order and EPS involvement—raised concerns about whether proper reporting protocols were followed.
Industry Standards for High-Risk Residents
Best practices in nursing home care require a multi-layered approach to elopement prevention for residents with cognitive impairment. This typically includes accurate risk assessment using validated screening tools, individualized care planning with specific interventions, physical monitoring devices such as wander guards, secure unit placement when appropriate, and comprehensive staff education.
For residents with complex social circumstances such as protective orders or custody disputes, additional protocols should include flagging charts with relevant legal documents, restricting visitor access as appropriate, training staff to recognize and respond to unauthorized removal attempts, and establishing clear communication channels with legal and protective services agencies.
The Heritage Manor case illustrates how gaps at any point in this system can create dangerous vulnerabilities. While individual components may have been in place—the wander guard was ordered, the resident was placed on a memory care unit—the failure to accurately document risk status, update monitoring lists, and communicate critical information about family restrictions ultimately allowed a vulnerable resident to be removed by an individual from whom she was supposed to be protected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Manor of Baton Rouge I I from 2025-02-21 including all violations, facility responses, and corrective action plans.
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