Failure to Accurately Document Resident Elopement in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation in a resident's electronic medical record (EMR) following an elopement incident. A registered nurse (RN) documented that the resident was found on the facility parking lot after eloping, despite knowing that the resident was actually found several miles away from the facility. This documentation was made at the direction of the former Assistant Director of Nursing (ADON), who instructed the RN to record that the resident was found on the facility campus. The Director of Nursing (DON) later verbally counseled the RN, emphasizing that false information should not be documented, regardless of who gives the instruction. The resident involved had a history of elopement from a prior secure facility and was identified as being at risk for elopement in their care plan. The resident was cognitively intact, had adequate hearing and vision, and had diagnoses including diabetes mellitus, seizure disorder, and schizophrenia. On the day of the incident, the resident was discovered missing during the morning medication pass, and a code white (elopement) was called. Staff later found the resident approximately 3.7 to 4.7 miles from the facility, after searching the surrounding area. Facility policy required that all documentation in the medical record be factual, accurate, and completed in a timely manner. The policy specifically prohibited the documentation of false information and required corrections to clarify inaccuracies. Despite this, the progress note entered by the RN did not accurately reflect the resident's location when found, resulting in a failure to maintain an accurate and complete medical record as required by facility policy and professional standards.