Failure to Notify Guardian of Resident Elopement and Multiple Falls
Penalty
Summary
The facility failed to notify a resident's court-appointed Guardian of significant changes in the resident's condition and incidents requiring treatment alteration. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia, PTSD, delirium, and anxiety, eloped from the facility without staff knowledge. Staff last observed the resident in the afternoon, but only became aware of the elopement when police arrived after finding the resident at a nearby hospital. The Guardian was not informed of the elopement until several days later, learning of the incident first from the resident's family and Adult Protective Services, rather than from facility staff as required by policy. Additionally, the resident experienced two falls on the same day. After the first fall, the Guardian was notified and an X-ray was ordered due to complaints of hip pain. However, following a second fall later that evening, the Guardian was not informed of this additional incident. The Guardian was only contacted after the X-ray revealed a hip fracture and consent was needed for hospital transfer. Interviews confirmed that staff did not notify the Guardian of the second fall, despite facility policy requiring notification of all changes in condition.