Failure to Complete and Document Quarterly Elopement Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for five residents, specifically by not completing required Quarterly Elopement Assessments since January 2025. Record review showed that none of the sampled residents had these assessments completed after 01/16/2025. Interviews with staff revealed that the previous MDS nurse had been responsible for creating a calendar to track when these assessments were due, but after her termination, the new MDS nurse did not assume this responsibility, stating it was not part of her job. As a result, neither the charge nurses nor the ADONs created the calendar, and the assessments were not performed. Further interviews with the ADON, MDS nurse, and DON confirmed that the lack of a tracking system led to the omission of the required assessments. The DON acknowledged that nursing staff were supposed to manage the assessment schedule but had not done so, resulting in incomplete documentation. The facility did not have a specific policy regarding Quarterly Elopement Assessments, as confirmed by the Administrator.