Failure to Immediately Notify Guardian After Resident Elopement
Penalty
Summary
The facility failed to immediately notify the resident's legal representative, a court-appointed guardian, after the resident eloped from the facility. The resident, an elderly female with severe cognitive impairment due to multiple strokes and other significant medical conditions, was discovered missing during evening rounds. Staff initiated a search, notified law enforcement, the administrator, the DON, and family members, but did not promptly contact the resident's guardian as required by facility policy and federal regulations. Record reviews and interviews revealed that the resident's guardianship had been established due to her cognitive deficits, and the guardian was listed as the responsible party. Despite this, there was confusion among staff regarding who was responsible for notifying the guardian, with some assuming that management would handle the notification. Documentation and interviews indicated that the guardian was not notified until several hours after the resident was found missing, with conflicting accounts of the exact timing of notification. The facility's policy required immediate notification of the legal representative within one hour of recognizing a significant change in the resident's condition, such as elopement. The delay in notifying the guardian was confirmed by both facility staff and the guardianship agency. The resident was eventually found several days later by a bus driver and transported to the hospital, where she was admitted for further assessment. The hospital case manager also noted that the guardian had not been notified in a timely manner about the elopement. The deficiency centers on the facility's failure to promptly inform the resident's legal representative of a significant event affecting the resident, as required by policy and regulation.