Westover Hills: Wandering Resident Care Plan Failures - TX

The incident occurred after Resident #1 had been exhibiting wandering and exit-seeking behaviors since August 5, according to nursing progress notes. Staff documented his behavior changes but never updated his assessments or care plans to help other workers respond appropriately.

Resident #2 told the wandering resident to leave her room, and he did. But the facility's systematic failure to communicate behavior changes left staff unprepared for future incidents.

The MDS Coordinator discovered the problem only on August 20 during routine monitoring. She told inspectors she had been out for personal reasons and wasn't aware the resident's condition had changed. "By not updating changes in the resident's care plan staff would not be aware of how to treat the resident," she said during an August 21 interview.

The facility uses a 24-hour reporting system where staff filter for key words to identify residents with condition changes. Assistant Directors of Nursing review these reports and update assessments accordingly. But the system broke down for Resident #1.

ADON D explained that three ADONs normally split the reports by hallway, but staffing disruptions complicated the process. One ADON had recently started, another had been out on FMLA leave. The Director of Nursing was helping read the daily reports to compensate.

"I was not aware of the nursing progress note from 8/5/25 where the resident was exhibiting exit seeking and wandering behaviors," ADON D told inspectors. Had she seen the note, she would have spoken to the resident, alerted nursing staff, and notified the DON. The facility would have contacted the doctor for potential order updates and revised the resident's elopement and wandering assessment.

The consequences extended beyond one resident. ADON D acknowledged that failing to update assessments "could cause someone to miss a new onset mental issue or condition, and implementing any interventions to protect other residents and respect their privacy."

The Director of Nursing learned about the August 5 nursing note only on August 20 while performing an audit — 15 days after the initial documentation. She told inspectors no one had ever reported that the resident was entering other rooms, despite the documented behaviors.

"I was unaware the resident ever had wandering behaviors," the DON said. She emphasized the importance of updating care plans and assessments "so staff could follow the residents plan of care and return him to his room safely."

The facility's own policy requires resident assessment updates whenever there's a change in mental or physical condition that may significantly affect daily living activities. The policy mandates quarterly assessments and additional evaluations as needed, including fall risk and pain assessments.

Staff are supposed to report significant changes to physicians and carry out new orders. The policy specifically mentions performing assessments like "enabling device assessment" when circumstances warrant.

But the policy wasn't followed for Resident #1. His wandering behaviors went unaddressed in his formal care planning for over two weeks, leaving nursing assistants without proper guidance on managing his condition.

The breakdown occurred despite multiple layers of oversight. Morning meetings between ADONs and the MDS Coordinator are designed to catch condition changes. The 24-hour reporting system with keyword filtering should flag behavioral incidents. Multiple ADONs reviewing reports by hallway creates redundancy.

None of these safeguards worked for Resident #1.

The facility eventually updated his care plan on August 20, but only after the DON discovered the gap during her audit. By then, the resident had spent more than two weeks wandering without appropriate interventions documented in his care plan.

Staff use care plans to understand resident behaviors and receive prompts through the point-of-care system nursing aides access. Without updated information, they couldn't provide appropriate responses to Resident #1's exit-seeking and wandering behaviors.

The inspection found the facility violated federal requirements for comprehensive assessments. Inspectors determined the violation caused minimal harm or potential for actual harm, affecting few residents.

Resident #2 successfully directed the wandering resident to leave her room, but the incident highlighted broader systemic failures in assessment protocols that could affect other vulnerable residents in similar situations.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Westover Hills Rehabilitation and Healthcare from 2025-08-21 including all violations, facility responses, and corrective action plans.

Additional Resources

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