Failure to Document Resident Elopement in Medical Record
Penalty
Summary
The facility failed to ensure that nursing staff documented a resident's elopement from the facility in the resident's medical record, as required by professional standards of practice. On the date of the incident, a resident with severe cognitive impairment and a history of dementia, epilepsy, and falls was last seen at the nurse's station before being discovered missing from their room. An elopement protocol was initiated, and the resident was found outside the facility by staff after being seen by visitors. The resident was returned to the facility, assessed for injuries, and placed on one-to-one supervision. A review of the resident's medical record revealed that there was no documentation of the elopement incident in the progress notes. The only note present was a nurse's progress note that did not mention the elopement, but instead documented a skin assessment and foot evaluation. Interviews with nursing staff confirmed that the elopement should have been documented in the resident's medical record, and that such incidents are typically charted post-incident to ensure all staff are aware of the event. The facility's own policy on nursing documentation requires that all changes in condition or behavior, as well as nursing interventions and observations, be documented accurately and promptly. The Director of Nursing and other leadership confirmed during interviews that elopement is considered a behavior that should be documented in the medical record. The lack of documentation for this incident was identified as a failure to follow both professional standards and facility policy.