The resident, who believed she was waiting for her brother to pick her up, had followed other people through the front door and climbed into what she thought was her brother's vehicle. When a certified nursing assistant walked to his car during his break around 2:45 PM, he found the resident sitting in his passenger seat.
"Okay," she said calmly when he told her she needed to come back inside.
Federal inspectors found the facility had failed to implement a care plan with interventions despite the resident's history of wandering, exit seeking, and altered mental status. The facility also failed to report the incident to state health officials within the required timeframe.
The resident told inspectors on May 1 that she was "going outside to wait on her brother, noticed a car that looked like her brother's and got in on the passenger side to wait until he signed her out." She said her brother normally came to take her out of the facility.
The front desk was unattended when the resident escaped. After she was found, staff notified the administrator and director of nursing. A skin assessment showed no injuries, and vital signs were taken. Her sister and nurse practitioner were contacted.
New orders came immediately. The resident received a wanderguard signaling device and a psychiatric consultation. A physician saw her the same day and ordered additional tests and medication changes. By May 2, she was placed on one-to-one supervision.
But the response came too late to prevent the immediate jeopardy citation. The facility didn't notify the Mississippi Department of Health until May 10, nine days after the incident.
The corrective actions rolled out that same day. The company president trained social services staff on implementing care plans for residents who verbalize wanting to leave, exhibit exit seeking behavior, or show signs of wandering. The director of nursing audited all 18 residents deemed at elopement risk to ensure their care plans included appropriate interventions.
Signs went up on all exit doors reminding staff and visitors to be cautious when entering and leaving. Letters went to family members requesting they notify staff if residents verbalize thoughts of leaving and use precautions when visiting.
The receptionist who left the front desk unattended received additional training on ensuring coverage before leaving her post. All staff who might cover the reception area received the same training.
An emergency quality assurance committee meeting convened May 10 with the company president, executive director, regional clinical director, director of nursing, two assistant executive directors, social service director, two social service assistants, and medical director. The infection prevention nurse participated by phone.
Federal inspectors validated the corrective actions during their May 12 complaint investigation and removed the immediate jeopardy citation on May 11.
The escape wasn't the only serious care failure inspectors found.
Resident #6 arrived at Brandon Community Care with a nephrostomy tube, a device inserted into the kidney to drain urine when normal urinary function is blocked. The hospital discharge records and admission notes documented the tube's presence.
But from admission through the May inspection, no one changed the tube's dressing or flushed it to prevent blockage. No documentation existed for any nephrostomy care. No physician orders addressed the device. No care plan mentioned it.
The neglect came to light through a complaint filed with the Mississippi Attorney General in August 2024. A hospital worker reported that when the resident was transferred to their emergency room, the attending physician noted the nephrostomy dressing hadn't been changed in 14 days.
The Attorney General's office couldn't substantiate criminal abuse or neglect but noted concerns about the quality of care and recommended the matter be reported to the state health department for investigation.
A registered nurse responsible for the resident's unit told inspectors she hadn't changed the nephrostomy dressing or flushed the tube since admission. "I didn't have any specific orders or schedule for the nephrostomy tube care, and I assumed that perhaps the wound care nurse or urology provider was managing it," she said.
She acknowledged no documentation existed for any dressing change or flush and said "it should have been done; we normally would at least change the dressing weekly." The nurse expressed concern that skipping these routines could lead to infection or tube blockage.
A licensed practical nurse who frequently cared for the resident said she wasn't aware of any care plan instructions or physician orders for the nephrostomy tube. She only monitored the site visually during her shifts and would address problems if it looked red or was leaking.
The director of nursing confirmed the facility's standard practice requires appropriate physician orders and nursing care routines for any resident with an invasive device. This includes regular dressing changes at least weekly and periodic tube flushing, with each instance documented in treatment records.
"We should have been flushing that tube and changing the dressing on a schedule and documenting it every time," she told inspectors. She described it as "a failure in care" and said staff should have contacted the physician or urology specialist upon admission to obtain orders if none were provided.
The facility's medical director said a nephrostomy tube requires routine care and monitoring to prevent complications. He expected nursing staff to notify him or a consulting urologist if specific orders were needed for maintaining the tube.
"According to standard care practices, a nephrostomy tube dressing should be changed regularly (e.g., at least weekly or when soiled) and the tube flushed as ordered to prevent blockage and infection," he said. The absence of documentation suggested these care tasks weren't being performed or recorded.
He confirmed the facility failed to follow professional standards, noting nursing staff should proactively ensure all devices receive proper care even if initial orders are missed.
The facility's weekly skin audit policy requires head-to-toe skin evaluations for every resident with documentation and treatment initiation for any identified conditions. But the policy wasn't followed for the nephrostomy site.
Brandon Community Care operates as Brandon Nursing and Rehabilitation Center at 355 Crossgate Boulevard. The facility houses two residents with nephrostomy appliances, meaning the care failure affected half of residents requiring this specialized service.
Federal inspectors found the facility had removed the immediate jeopardy conditions by May 11, but the nephrostomy care violations remained unresolved at the time of their departure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brandon Community Care Center from 2025-05-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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