Failure to Complete SBAR Communication Tool After Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to complete the SBAR (Situation, Background, Assessment, Recommendation) communication tool for a resident who experienced a change in condition and subsequently eloped from the facility. The resident, who had diagnoses including schizoaffective disorder, epilepsy, and hypertension, was admitted with intact cognition and required moderate assistance with activities of daily living. On the day of the incident, the resident was found missing from the facility, prompting staff to search the premises. The attending physician was notified by phone, but the responsible LVN did not complete the SBAR form, citing being preoccupied with the search for the resident. The Director of Nursing confirmed that the SBAR form should have been completed in response to the resident's change in condition and elopement, as it is a critical tool for ensuring clear communication among staff and with the physician. Facility policies required detailed observations and completion of the SBAR form prior to physician notification, as well as complete and accurate documentation of any changes in a resident's condition. The failure to complete the SBAR resulted in an incomplete clinical record and potential miscommunication regarding the resident's status.