Failure to Notify Physician and Representative After Resident Went Missing
Penalty
Summary
The facility failed to notify a resident's physician and representative when there was a significant change in the resident's status, specifically when the resident was found missing. The resident, a male with severe cognitive impairment due to unspecified dementia and other psychiatric diagnoses, was admitted for a respite stay and was noted to have increased wandering behavior. On the day of the incident, staff discovered the resident was missing, initiated a search, and found him after a short period. Documentation revealed no evidence that the resident's representative or physician was notified about the wandering or the missing event. Interviews with facility staff indicated confusion and lack of clarity regarding notification responsibilities. The ADON reported being informed by a nurse that the resident was missing and subsequently notified the Administrator, who was already present in the building. The Administrator stated she notified the hospice company but did not notify the physician and believed the hospice company would inform the family. Nursing staff believed that the Administrator and ADON would handle notifications, and the family representative confirmed that notification came from the hospice company, not the facility. Facility policy required documentation of changes in a resident's condition and notification of family, physician, or other staff. However, the records lacked documentation of such notifications for this incident. Staff interviews further confirmed that the physician and family representative were not directly notified by the facility, and the Administrator acknowledged that the physician should have been notified but was not.