Failure to Notify Resident Representatives After Significant Behavioral Incident
Penalty
Summary
The facility failed to notify a resident's physician and representatives following a significant change in the resident's behavior, specifically an increase in exit-seeking behavior that resulted in police intervention. The resident, a male with diagnoses including schizoaffective disorder, type 2 diabetes mellitus, and dementia, had a documented history of wandering and was assessed as being at risk for elopement. On the night of the incident, the resident left the facility through a secured door, setting off an alarm, and was pursued by staff who were unable to redirect him. The situation escalated to the point where police were called, and the resident was physically restrained and returned to the facility by law enforcement. Despite the seriousness of the event, there was no documentation that the resident's emergency contacts were notified of the incident until several days later. Both emergency contacts reported learning about the incident through a family member who saw it on social media, rather than from the facility itself. Interviews with staff and administration confirmed that there was no immediate notification to the resident's representatives, and the facility's electronic medical record did not show any timely communication regarding the police intervention or the resident's attempted elopement. The facility's policy required prompt notification of the resident, physician, and representative in the event of significant changes in condition or incidents involving the resident. However, the Director of Nursing stated that the incident was not considered a change of condition due to the resident's history, and therefore, notification was not deemed necessary at the time. This lack of timely communication was confirmed by both the DON and the administrator, as well as by the absence of documentation in the resident's records.