Robert Lee Care Center admitted Resident #31 with diagnoses including dementia with psychotic disturbance, delusions, hallucinations, and depression. The resident's quarterly assessment revealed a BIMS score of 2, indicating severe cognitive impairment and disorganized thinking.
The assessment also documented wandering and rejection of care occurring one to three days during the review period. Yet the facility's care plan from April contained no focus, goal, or intervention section addressing either behavior.
Nobody had planned for the wandering.
During the December 31 inspection, the Director of Nursing acknowledged the oversight. She told inspectors these behaviors should have been care planned because they were part of the resident's behavior and needed documentation. The DON said the care plan's purpose was to provide care for the resident and ensure everyone knew what the resident needed.
The MDS coordinator confirmed there was no wandering or rejection of care planning for Resident #31. She told inspectors it should have been care planned for the resident's wandering "to be able to keep an eye on her." The coordinator stated the care plan's purpose was to notify staff of the resident's behaviors.
Both staff members acknowledged the failure created risks. The MDS coordinator said the risk was needs not being met.
The facility's own policy required comprehensive, person-centered care plans developed by the interdisciplinary team with residents and families. The policy mandated plans describe services furnished to attain or maintain residents' highest practicable physical, mental, and psychosocial well-being.
The inspection found the facility violated federal requirements for complete care plans with measurable objectives and time frames. Inspectors determined the deficient practice could place residents at risk of not receiving necessary care or having personalized plans developed to address their needs.
For a resident with severe cognitive impairment experiencing both wandering and care rejection, the absence of behavioral interventions left staff without protocols for managing potentially dangerous situations. Wandering poses particular risks for dementia patients, who may become lost, injured, or exit the facility unsupervised.
The DON told inspectors the MDS department was responsible for ensuring behaviors were care planned. The MDS coordinator accepted this responsibility, confirming it was the MDS department's job to ensure care plans were correct.
The facility's March 2022 care planning policy outlined clear requirements for comprehensive plans addressing all resident needs. The policy specified that plans must be developed in conjunction with residents and their families or legal representatives.
Despite these written policies and staff acknowledgment of the importance of behavioral care planning, Resident #31's documented wandering and rejection of care went unaddressed in the formal care plan for months.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to plan for documented behaviors in a resident with severe cognitive impairment and multiple psychiatric diagnoses highlighted broader concerns about the facility's care planning processes.
Federal regulations require nursing homes to develop and implement complete care plans meeting all residents' needs. The plans must include timetables and measurable actions to help residents achieve their highest level of functioning.
The Robert Lee Care Center inspection revealed a gap between policy and practice. While staff understood the necessity of behavioral care planning and could articulate its purpose, they failed to implement these plans for a vulnerable resident with documented challenging behaviors.
The MDS coordinator's statement that wandering care plans were needed "to be able to keep an eye on her" underscored the practical implications of the oversight. Without formal protocols, staff lacked structured guidance for monitoring and responding to the resident's behavioral needs.
Resident #31 remained at the facility with severe cognitive impairment, documented psychiatric conditions, and challenging behaviors that staff had identified but failed to address through proper care planning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robert Lee Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.