Failure to Notify Physician of Resident's New Wandering Behavior
Penalty
Summary
The facility failed to notify the physician when a resident exhibited new wandering behavior, which was a change in condition. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and depression, and was assessed as having severe cognitive impairment and lacking decision-making capacity, was found outside the facility by a nurse. This incident was not communicated to the physician as required by the facility's policy, which states that the physician must be notified of any accident or incident involving a resident. Multiple staff interviews confirmed that the resident had a history of wandering and aggressive behavior when denied certain items, such as hot chocolate. The lack of physician notification resulted in the resident's wandering behaviors not being addressed, which subsequently led to a physical altercation between this resident and another. The staff and another resident reported that the wandering resident would take food and drinks from others and from carts, and that this behavior was known among staff. The Assistant Director of Nursing acknowledged that the physician should have been notified of the new behavior, specifically when the resident was found outside the facility, and that failure to do so could delay care.