Failure to Timely Notify POA After Resident Elopement and Injury
Penalty
Summary
The facility failed to promptly notify a resident's Power of Attorney (POA) and provide a comprehensive report following an elopement incident. The resident involved had diagnoses including Alzheimer's Disease and Hypertensive Heart Disease with Heart Failure, was severely cognitively impaired, and had a documented history of wandering and exit-seeking behaviors. The care plan included interventions such as redirecting the resident, notifying staff of exit-seeking tendencies, providing diversional activities, and conducting 30-minute checks. On the date of the incident, the resident was found by an off-duty police officer approximately 0.2 miles from the facility, sitting in a vehicle with visible injuries including a laceration on the left eyebrow and abrasions on the hands, wrists, and elbows. The resident was disoriented, unable to state his address, and was subsequently transported to the emergency department for evaluation. Medical records confirmed the injuries and noted that the resident had escaped from the memory care unit, tripped, and fallen on the street before being returned to the facility. The facility did not notify the resident's POA until after the resident had returned from the emergency department, several hours after the elopement and subsequent injuries occurred. The POA reported being upset about not being informed when the facility first became aware of the elopement and not receiving full details of the event. Facility policy required prompt assessment and notification of a resident's designated medical contact in the event of a change in condition, which was not followed in this case.