Hale Makua - Kahului

F-F657. The facility failed to revise Resident (R)1's care plan following an incident of actual elopement and unsafe wandering (wandering into other residents' rooms).

The facility submitted an Event Report on 12/06/24 at 08:30 PM regarding Resident R1's elopement. On 12/06/24, Resident R1 was found outside near fence in back of unit. Resident R1's WanderGuard (a system that provides wander management for those at risk of elopement) bracelet reportedly was in place and functioning at the start of

the shift. No alarms were heard.

The final report was submitted on 12/10/24 at 02:35 PM. The facility clarified, Resident R1 was found outside of the building behind the activities center. The House Supervisor saw the WanderGuard alert on another unit (North) and notified Resident R1's unit (Pikake). Another staff member saw Resident R1 from the window of another unit (Ilima) and notified the Pikake unit. The facility's investigation found the door to enter the activities department from

the Pikake unit was not locked and Resident R1 was able to enter the room and access the emergency exit door at the rear of the building. The emergency exit door is equipped with a locking mechanism that will allow the exit door to open after being held for 15 seconds.

On 01/13/25 at 10:50 AM record review was done. Resident R1 was readmitted to the facility on [DATE REDACTED]. Diagnoses include but not limited to unspecified dementia, unspecified severity with anxiety; unspecified dementia, unspecified severity with agitation; nondisplaced intertrochanteric fracture of left femur (routine healing); cognitive communication deficit; aphasia (a language disorder that makes it difficult to understand or express language); and anxiety disorder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/21/24 notes Resident R1 has severe cognitive impairment and was coded for wandering behavior. Resident R1 requires supervision or Level of Harm - Minimal harm or touching assistance for walking. potential for actual harm

A review of the Elopement Risk Evaluation dated 10/24/24 documents Resident R1's risk score was 5 (high risk - Residents Affected - Some further assessment is needed). Interventions recommended included elopement deterrent device implemented and elopement prevention care plan initiated or updated. Subsequent assessment dated [DATE REDACTED] (following actual elopement), Resident R1's risk score was 3 (moderate risk - improvement) with intervention recommended for elopement prevention care plan initiated or updated.

Review of Resident R1's care plan for behavioral symptoms with a start date of 11/09/22 identifies Resident R1 has depression and agitation and may demonstrate the following challenging behaviors: agitation, restlessness, anxiety, wandering exit seeking behaviors, entering other resident's room, and refusal of care. An approach with start date of 08/23/23 was developed for wandering. Approaches include, ask me if I need anything or offer me drink/food/toilet/lie down/activity; monitor my whereabouts; provide redirection and reorientation as needed, state what I should do, not what I should not do; follow me for safety until I can be redirected; and I was issued a WanderGuard device that locks exit door when I approach.

Other approaches include: being at risk for wandering/elopement due to cognitive impairment, refer to wandering care plan (start date 03/14/23); resident may express confusion and insist on going home, at

these times, do frequent visual checks, as I may wander off unit, flow sheet for every hour (start date of 08/01/24); I use a Wander Guard, please check the placement every shift (start date of 06/23/23); and a falls care plan to monitor resident frequently for safety, encourage to take rest periods in between walking activity, when walking, I may become agitated when staff tells me that I require assistance, encourage me to use my walker and take breaks; and if I appear restless, increase rounding until I am calm.

A review of the progress notes from 11/29/24 to 01/12/25 found documentation of Resident R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, Resident R1 wandered into another resident's room at night; 12/08/24 at 03:30 PM, Resident R1 sometimes walks into other residents' rooms looking for the toilet; 12/15/24 at 08:55 PM, Resident R1 was wandering a lot on the unit and it was reported Resident R1 was found in another resident's room. The documentation in the progress notes were not detailed to identify which rooms Resident R1 entered, what she was doing in the room, if other residents were present at that time, what interventions were tried to deter the behavior. There were other entries documenting Resident R1 wandering on the unit, going from room to room and standing at the door, and exit seeking behavior.

On 01/13/25 at 01:16 PM, observed Resident R5 seated by the door of her room, Resident R5 reported Resident R1 was once found in her room, sitting on the toilet. Resident R5 resides in room [ROOM NUMBER]. Resident R5 reported being surprised to find Resident R1 using her toilet. Upon discovery, Resident R5 stated Resident R1 shook her finger at her to indicate Resident R5 was in the wrong. Resident R5 also reported seeing Resident R1 stand in front of other residents' doors, blocking their way into their room and walking about the unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 01/13/25 at 02:11 PM, observed Resident R1 in a wheelchair, self-propelling on the unit. Did not observe staff members employing approaches for wandering. At 02:17 PM, observed Resident R1 enter room [ROOM NUMBER]. Level of Harm - Minimal harm or Resident R1 transferred herself from the wheelchair onto Bed A and laid down. At 02:30 PM observed two staff potential for actual harm members enter the room, they stood by the foot of Bed A, then exited the room. At 02:35 PM, observed Certified Nurse Aide (CNA)1 enter room [ROOM NUMBER], the curtain was drawn closed while CNA1 Residents Affected - Some assisted Resident R1 back to the wheelchair. CNA1 wheeled Resident R1 back to her room and assisted Resident R1 back to bed.

On 01/13/25 at 02:40 PM, interviewed CNA1. CNA1 confirmed Resident R1 was in the wrong room. Inquired what are

the approaches used to for Resident R1's wandering. CNA1 reported the nurses know what to do. Further queried as

an aide, what is she supposed to do, CNA1 responded she doesn't know what to do but the nurses know. CNA1 was asked how often is Resident R1's whereabouts monitored, CNA1 responded one to two hours.

On 01/14/25 at 07:50 AM interviewed the Unit Nurse (UN) at the Pikake unit in the nurses' station. Reviewed

the progress notes with the UN. Inquired about incident of 11/29/24 when staff discovered Resident R1 in a resident's room and the team decided to place a Stop banner in the doorway. UN initially could not recall the incident and later stated this entry documents Resident R1 was found in room [ROOM NUMBER] and the team agreed to place a Stop banner on the door.

Concurrent review of the progress notes documenting incidents of Resident R1 wandering into other residents' rooms was done with UN. Requested UN review the care plan for revisions after the incidents. UN was unable to confirm Resident R1's care plan approaches were revised to address wandering into other residents' rooms. Based on

the progress notes, UN was unable to identify which rooms Resident R1 wandered into and stated it isn't feasible to place Stop banners in all residents' doorways to prevent Resident R1 from entering.

Concurrent observation of room [ROOM NUMBER] was done with the UN. There was a banner affixed to the doorway which was not placed across the doorway. Inquired when does the facility use the banner, UN responded it is up to the resident.

Further review of the Treatments Administration History (TAH) for December 2024 found a flow sheet for the approach to check WanderGuard placement every shift with instruction to use (+) present and (-) not. The flow sheet for December 2024 had entries documenting the WanderGuard was not present (-) for the following dates and shifts: 12/05/24 - NOC; 12/07/24 - PM; 12/09/24 - day; 12/12/24 - PM shift; 12/15/24 - PM; 12/16/24 - PM; 12/17/24 - day; 12/17/24 - PM; 12/23/24 - PM; 12/23/24 - NOC; 12/26/24 - day; 12/26/24 - PM; and 12/27/24 - NOC.

There was also a flow sheet to monitor the following target behaviors: 1) agitation, 2) restlessness, 3) anxiety, 4) depression, 5) ambulate without assistance, 6) refuse care/treatment, and 7) poor appetite. Of the 63 opportunities to document for ambulating without assistance, there were only five entries to document Resident R1 ambulated without assistance. This documentation was inconsistent with the progress note entries which noted 17 entries of wandering on unit (ambulating without assistance) and exit seeking behavior.

Requested additional information on the morning of 01/14/25 to demonstrate the multidisciplinary team met to do root cause analysis and update Resident R1's care plan. The facility provided a grievance report from Resident R6 complaining that Resident R1 has been wandering into her room every night and was awakened to find Resident R1 staring at her. The team agreed to place a Stop banner across the Resident R6's room and nursing staff was reeducated regarding wandering residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 01/14/25 at 11:07 AM interviewed the Administrator. The Administrator explained the staff reenacted the event and found that the WanderGuard triggered at the North unit, however, the alarm to the emergency exit Level of Harm - Minimal harm or could not be heard on the unit as the door was closed. The Administrator reported the team consulted the potential for actual harm physician and assessed a possible causal factor was the drug interaction of Remeron (antidepressant) and Sertraline (antidepressant) may have contributed to increase in wandering behavior. Resident R1's Sertraline dosage Residents Affected - Some was decreased to 75 mg for seven days, then 50 mg after the first seven days.

On 01/14/25 at 01:05 PM, discussed inconsistent documentation of wandering and elopement occurrences with the Administrator. Administrator reported the charting may be done according to who observes the behavior, the nurses or the aides. The Administrator provided documentation, Point of Care History for 11/14/24 to 12/14/24. There were six entries to indicate interventions were taken to alter wandering. Administrator reported the electronic record needs to be programmed for the aides to document wandering behavior. Inquired when was this behavior loaded to enable the aides to document this behavior. The Administrator was not sure.

2) Cross Reference to

F-F686, Comprehensive Care Plan. The facility did not ensure Resident R2's care plan was implemented consistently to monitor resident's targeted behavior of wandering every shift and ensuring the functioning of WanderGuard functioning once a day.

Observation on 01/13/25 at noon saw Resident R2 seated in a wheelchair in the hall next to the door of her room.

Observation at 01:00 PM, Resident R2 was standing at a table with two other female residents and talking. Subsequently, Resident R2 was observed to follow staff around the unit. Resident R2 was independently ambulatory. Later Resident R2 was observed sitting at a table by the nurses' station, watching television. Later observed Resident R2 seated in activities for volleyball, Resident R2 was smiling.

On 01/13/25 at 01:39 PM a record review was done for Resident R2. Resident R2 was admitted to the facility on [DATE REDACTED]. Diagnoses include but not limited to, Alzheimer's with early onset; dementia in other diseases classified elsewhere, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety; chronic kidney disease, stage 2 (mild); wandering in diseases classified elsewhere; and other abnormalities of gait and mobility.

A review of the quarterly MDS with an ARD of 11/26/24 noted Resident R2 was assessed with moderate cognitive impairment for decision making skills. Resident R2 was also coded for wandering behavior, occurred one to three days

during the assessment period.

The facility developed a care plan during the survey for Resident R2 being at risk for elopement due to history of wandering and severe cognitive impairment. Approaches included: if I am going toward unit exit, please help me back to my room where staff can supervise me; I use a WanderGuard for safety, please check the placement every shift; if I become agitated and difficult to redirect, I may require 1:1 supervision to manage my wandering; and please refer to my activity care plan for my preferences and things that interest me.

Prior approaches for wandering with a start date of 02/09/21 included but not limited to: 12/17/22 - WanderGuard to my dominant risk (right side) as I tend to wander around at night and attempt to leave the facility out of curiosity. Monitor my WanderGuard is in place every shift; and 12/27/22 - Wandering/exit seeking, when observed redirect me to my unit/room, offer me something to eat/drink or offer me to use the bathroom, encourage me to engage in group activities every shift

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Further review found no Wandering/Elopement Risk assessment was done since Resident R2's admission. On 01/13/25 at 03:13 PM, requested to review Resident R2's wandering/elopement risk assessment. At 03:30 PM, the Level of Harm - Minimal harm or Administrator and Administrator in Training (AIT) reported they could not find an assessment but would potential for actual harm continue to locate an assessment. The facility did not provide documentation of wandering/elopement risk assessment prior to exit. Residents Affected - Some

The Treatments Administration History (TAH) for December 2024 and 01/01/25 through 01/14/25 found an order to monitor target behaviors, wandering and refusal of medication. There were missing entries for the following dates-shifts: 11/07/24 - day, 11/11/24 - PM, 11/18/24 - PM, 12/08/24 - day shift, 12/16/24 - day shift, 01/02/25 - day shift, and 01/02/25 - PM shift. The entry spot for Exhibited Behavior # was populated with 0s and 1s. There was also an area to document, Intensity Before, and Frequency Before. It was unclear what the numbers represented.

Further review noted missing entries to ensure functioning of WanderGuard (start date of 12/27/24) on the following dates, 12/29/24, 12/30/24, 01/03/25, 01/04/25, and 01/08/25.

On 01/14/25 at 10:20 AM, an interview with the UN was done. The UN reported the coding for exhibited behavior # is: 1 for documenting wandering behavior and 2 for refusal of medication and a 0 would indicate there were no behaviors observed.

On 01/14/25 at 11:07 AM, interviewed the Administrator and Administrator In Training (AIT). Administrator reported, she was surprised Resident R2 did not have an elopement risk and a care plan as the facility audited the chart. Administrator acknowledged the TAH for monitoring of target behaviors (wandering and refusal of medication) could be confusing and they will considering separating the two behaviors.

Review of the facility's policy and procedures entitled Wandering/Elopement Risk Assessment with original effective date of 05/0/21 notes the facility will assess all patients/residents for elopement potential in order to provide a safe and comfortable living environment. The policy includes but not limited to the following:

3) Patients/residents are re-assessed for elopement potential by the MDS Nurse/Social Service/Nurse or designee quarterly throughout a patient's/resident's stay and with a significant change.

4) Interventions will be added to the patient's/resident's care plan after analyzing the information obtained.

5) The licensed nurse or social service designee completes the Elopement Risk Evaluation and presents the information to the Interdisciplinary Team for further interventions.

3) Resident R3 was admitted to the facility on [DATE REDACTED]. Diagnoses include but not limited to unspecified dementia, unspecified severity without behavior disturbance, psychotic disturbance, mood disturbance and anxiety; Type 2 diabetes mellitus, and primary osteoarthritis.

On 01/13/25 at 10:10 AM an entrance interview was conducted with the Administrator. Requested a list of residents that eloped from the last recertification survey done on 10/18/24 to present. At 11:18 AM, the Administrator reported there were no other incidents of elopement and provided a listing of residents who wear WanderGuard devices. Resident R3 was selected from this listing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 01/13/25 at 02:56 PM a record review was done. The quarterly MDS with an ARD of 12/30/24 noted Resident R3 was assessed with moderate cognitive impairment. Resident R3 was not coded to exhibit wandering behavior in the Level of Harm - Minimal harm or assessment period. A review of the Elopement Risk Evaluation dated 09/14/24 indicated Resident R3 was assessed potential for actual harm at high risk (further assessment is needed) for elopement risk. There was no documentation of a subsequent quarterly risk evaluation completed for December 2024. Residents Affected - Some

Review of the care plan with start date of 06/26/24 for risk of elopement had the following approaches with a start date of 01/13/25, ensure an elopement assessment is done on me quarterly and/or PRN as necessary.

A review of the progress notes found an entry dated 11/12/24 at 08:59 AM by social services documenting social services heard exit alarm and found resident outside of East exit door in front of SS office. A review of

the facility's campus map notes the East Entrance is across the social services' office. Further review found no follow up elopement risk assessment or care plan revision.

On 01/14/25 at 10:10 AM, Administrator confirmed the East Entrance is equipped with WanderGuard system. On 01/14/25 at 10:15 AM interview with UN was done at the nurses' station. Concurrent review of

the progress notes of 11/12/24 was done. UN reported that this was not an elopement, Resident R3 was found outside of the social services' office within the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 125007

F-F689. Resident (R)1 had an actual elopement on 12/06/24 and wandering behavior that places Resident R1 at risk for falls, resident to resident altercations, and elopement.

Review of Resident R1's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 10/21/24 notes Resident R1 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. Resident R1 was also coded for wandering, occurring one to three days during the observation period. Resident R1 requires supervision or touching assistance for walking 10 feet, walking 50 feet with two turns, and walking 150 feet.

A review of Resident R1's progress notes from 11/29/24 to 01/12/25 found entries of Resident R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, Resident R1 wandered into another resident's room at night; 12/08/24, Resident R1 sometimes walked into other residents' room looking for the toilet; and 12/15/24 at 08:55 PM, Resident R1 was wandering a lot on the unit and was found in another resident's room.

Review of Resident R1's care plan found approaches for wandering with a start date of 08/23/23. Approaches/Interventions included: ask me if I need anything or offer me drink/food/toilet/lie down/activity; monitor my whereabouts; provide redirection and reorientation as needed, state what I should do not what I should not do; follow me for safety until I can be redirected, I was issued a WanderGuard device that locks exit door when I approach.

There were no care plan revisions to assess the efficacy of current approaches and/or to develop new approaches following actual event of elopement and incidents of resident entering other residents' rooms.

On 01/14/25 at 07:50 AM an interview and concurrent record review was done with the Unit Nurse (UN). Inquired whether the facility revised Resident R1's care plans after the wandering incident on 11/29/24. UN stated the team decided to place a Stop banner across the door of the room Resident R1 entered. UN also stated it wouldn't be feasible to place these banners across all residents' doorways to prevent Resident R1 from entering. UN was unable to confirm Resident R1's care plan was revised.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 125007 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 125007 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 22063

Residents Affected - Some Based on observations, record review, and interview with staff members, the facility failed to implemented residents' care plans to eliminate risk of an accident related to wandering and elopement and monitor the effectiveness of interventions as necessary for 3 of 4 (Residents 1, 2, and 3) residents sampled.

1) Resident (R)1 had an actual elopement, the facility failed to revise the resident's care plan to develop person centered interventions, direct care staff were unaware of approaches/interventions to employ for Resident R1's wandering behavior and the wandering and exit seeking behaviors were not accurately monitored resulting in no baseline data to determine the efficacy of the interventions.

2) The facility failed to develop a care plan to prevent elopement for Resident R2 with wandering behaviors prior to the start of the survey. The facility also did not implement or accurately document care plan approaches for monitoring the function of WanderGuard once a day and the targeted behaviors (wandering and refusal of medications).

3) The facility did not implement Resident R3's care plan to assure an elopement assessment was done quarterly. The facility also did not recognize an elopement incident, resulting in no assessment of the incident and need for care plan revision.

Findings include:

1) Cross Reference to