Failure to Timely Notify Resident Representative of Elopement Incident
Penalty
Summary
The facility failed to notify the resident representative of a significant change in a resident's condition when a resident with severe cognitive impairment exited the facility unattended. The resident, who had diagnoses of schizoaffective disorder and dementia and required supervision or assistance for ambulation, was observed by staff outside the facility after opening an exit door. Following this incident, a wander guard was applied to the resident, and the care plan was updated to address the elopement risk. Despite these interventions, the resident's representative was not informed of the incident or the new safety measures until nearly two weeks later, after the recertification survey had begun. Documentation and staff interviews confirmed that the expectation was for timely notification of the resident's representative or guardian in such situations, but this did not occur in this case.