Failure to Document Resident Elopement Event in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation of an elopement event. The resident, who had multiple medical diagnoses including congestive heart failure, cognitive decline, major depressive disorder, and Parkinson's disease, was identified as high risk for falls and elopement, with a history of confusion and exit-seeking behaviors. On the night in question, the resident left the facility in a wheelchair and was later found in the community by a local resident, after which a head count confirmed the resident was missing. Upon return, the resident was assessed and a wander guard was applied. The facility's investigation file included staff statements and noted that notifications were made to the administrator, supervisor, and the resident's representative. However, a review of the resident's medical record revealed that there was no documentation of the elopement incident, including the event itself or the notification to the resident's representative. The facility's policies require timely and accurate documentation of incidents, including notifications and interventions, in the clinical record. The Director of Nursing was unaware of the lack of documentation until it was brought to her attention. The absence of this documentation constitutes a failure to maintain medical records in accordance with accepted professional standards.