Failure to Notify Resident Representative After Elopement
Penalty
Summary
The facility failed to notify a resident's representative after the resident, who was severely cognitively impaired and diagnosed with alcohol dependence with alcohol-induced persisting dementia, Wernicke's encephalopathy, and chronic kidney disease, was found outside of the facility on multiple occasions. Documentation showed that the resident was found by staff outside by the dumpster, sitting in a visitor van, and exiting through a back door with a broken lock. In each instance, staff responded by returning the resident to the facility and documenting the events in the progress notes, but there was no documentation that the resident's representative was notified of these incidents. Interview with the resident's family member, who is also the legal guardian, confirmed that she was not informed by the facility about the resident leaving the premises. The family member stated she only learned of one incident through her sister, not directly from the facility. Facility policy requires that the responsible party be notified in the event of a resident attempting to leave or leaving the premises, but this was not followed in the case of this resident. The administrator confirmed that staff are expected to notify the representative immediately and document the notification, which did not occur.