Failure to Document Resident Elopement and Investigation
Penalty
Summary
The facility failed to document an elopement incident and subsequent investigation in the medical record of a resident with dementia, weakness, muscle wasting, and severe cognitive impairment. The resident, who was independently mobile and assessed as at risk for elopement, was found outside the facility by a CNA after exiting through an unlocked and unalarmed door leading to a courtyard, and then through an unlocked gate to the sidewalk. The incident was observed by staff, and the resident was returned to the facility without any door alarms sounding. The unlocked gate was attributed to a mowing contractor's access, and the exit door was routinely left unlocked and unalarmed to allow residents to access a smoking area. Despite the occurrence of the elopement, there was no documentation of the incident in the resident's nursing progress notes or electronic medical record, except for a note in a risk section not typically accessible to medical or nursing staff. The facility's elopement investigation did not identify or document the root cause of the incident, nor did it note the status of the doors and gate at the time. The Director of Nursing was unsure if the elopement was documented in the resident's medical record, confirming the lack of proper documentation.