Failure to Maintain Accurate Elopement Risk Assessments and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a history of dementia and cognitive impairment. Although the care plan identified the resident as being at risk for elopement and required quarterly reassessment, there was no documentation of elopement risk assessments in the clinical record except for one completed after an actual elopement event. The facility's policy required new assessments after any actual or attempted elopement or when exit-seeking behaviors were identified, but these were not documented as required. The resident exhibited wandering behaviors, including an incident where the resident left the floor, exited the building, and was found outside by a staff member. Despite these behaviors and the facility's policy, the required elopement risk assessments were not completed or documented in the clinical record prior to the elopement event. The administrator confirmed that paper assessments could not be located and that the assessments were not transcribed into the clinical record, resulting in incomplete and inaccurate documentation.