Failure to Document Elopement and Related Events in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, alcohol-induced dementia, and moderate cognitive impairment. The resident was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors, as documented in the care plan. Despite these risks, the resident was able to leave the facility undetected and was later found by a staff member after having spent the night away from the facility. A review of the resident's medical record revealed significant gaps in documentation. There were no nursing progress notes related to the resident being observed missing, notifications to family, physician, or police, the resident being found, being taken to the hospital, or returning to the facility. The last progress note prior to the incident was dated several weeks before, and the next note was entered days after the resident's return, with no mention of the elopement event or related actions. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that documentation of the incident and subsequent notifications was not completed as required by facility policy. The policy specified that events, incidents, or accidents involving the resident, as well as changes in condition and notifications, should be documented in the medical record. The lack of documentation represented a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.