Failure to Assess and Accurately Document Elopement Risk and Behaviors
Penalty
Summary
The facility failed to complete a nursing assessment and elopement risk assessment for a resident at the time of readmission, despite the resident having diagnoses including dementia, unsteadiness on feet, and generalized muscle weakness. The resident had a BIMS score indicating severe cognitive impairment. Documentation showed that the resident exhibited wandering and exit-seeking behaviors shortly after readmission, including an attempt to exit through the front door and later being found outside the facility in the parking lot. However, there was no evidence in the medical record that an elopement risk assessment was performed at readmission as required by facility policy. Additionally, the behavioral section of the resident's Minimum Data Set (MDS) was not completed accurately. The staff member responsible for this section did not review the resident's progress notes and instead relied on verbal reports from other staff. As a result, the MDS did not reflect the resident's wandering and exit-seeking behaviors. Interviews with facility staff confirmed that the required assessments were not completed and that the behavioral section of the MDS would have been completed differently if the progress notes had been reviewed.