Failure to Notify Responsible Parties of Resident Elopement
Penalty
Summary
The facility failed to notify the responsible parties of two residents who eloped from the facility. Both residents had severely impaired cognition, with one diagnosed with Alzheimer's disease, adjustment disorder, mood disorder, and delirium, and the other with dementia, traumatic brain injury, falls, and muscle weakness. On two separate occasions, each resident exited the facility through the front doors and was observed and redirected back inside by staff. However, there was no documentation in either resident's clinical record indicating that their responsible parties had been informed of these elopement incidents. Interviews confirmed that at least one family member was not made aware of the elopement. The facility's own policy required that the family or legal representative be notified upon the return of an eloped resident, but this was not followed. The deficiency was identified through a complaint received by the State Agency and confirmed by record review and interviews.