Incomplete Documentation Following Resident Elopement
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented following an incident of elopement. The resident, who had diagnoses including aphasia, muscle wasting and atrophy, vascular dementia, and a history of transient ischemic attack and cerebral infarction, was found outside the facility after being let out to the front patio by a staff member. The resident, who is non-verbal, was discovered approximately 75 feet down the parking lot and was unable to explain the wandering event. The clinical record for this resident did not contain a follow-up note or any documentation after the day of the elopement. The only note present from the day of the incident included a basic assessment and vital signs, as well as mention of scrapes to the right leg, but lacked documentation regarding care provided for the scrapes, completion of an elopement risk assessment, or placement and documentation of a wander guard. There was also no documentation regarding any subsequent wandering behaviors or attempts since the incident. The Nursing Home Administrator confirmed these documentation gaps, indicating that the facility did not maintain complete and accurate medical records as required.