Failure to Notify Physician and Guardian of Resident's Change in Condition and Elopement Attempts
Penalty
Summary
The facility failed to notify a resident's physician and legal guardian of significant changes in the resident's condition, including medication refusal, exit-seeking behavior, multiple elopement attempts, and an actual elopement that resulted in serious injury. The resident, who had severe cognitive impairment due to dementia and a history of behavioral disturbances, was admitted with known risks for wandering and elopement. Despite documented incidents of the resident attempting to exit through windows and doors, and refusing medications, there was no evidence in the medical record that the physician or guardian was informed of these events. Staff interviews revealed that multiple team members, including CNAs and nurses, were aware of the resident's repeated exit-seeking behaviors and previous elopement attempts, both at the current and prior facilities. The resident had previously eloped from the first floor and attempted to jump from a balcony and windows on the second floor. Staff did not notify management, the physician, or the guardian about these incidents, assuming that others were already aware or that such notifications were unnecessary. The facility's own policy required prompt notification of the physician and representative in the event of significant changes, accidents, or behaviors that could require intervention, but this was not followed. The deficiency culminated in a serious incident where the resident fell from a second-floor window, sustaining multiple fractures and requiring acute hospitalization. Interviews with the physician, nurse practitioner, and guardian confirmed that they were not notified of the resident's escalating behaviors, medication refusals, room changes, or elopement attempts. The lack of communication and failure to follow policy directly contributed to the deficiency identified by surveyors.