F0842

D

Failure to Document Incident Involving Elopement-Risk Resident

Story City, Iowa Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document an incident in which a resident left the facility unattended and later returned with staff. The resident had a BIMS score of 9, indicating moderately impaired cognition, and diagnoses including hypertension, Alzheimer’s disease, non-Alzheimer’s dementia, cataracts, glaucoma, and macular degeneration. The MDS documented that the resident could understand and be understood, had no documented behaviors such as wandering or rejecting care, and was independent with personal hygiene and ambulation using a 4-wheeled walker. The care plan, however, identified the resident as an elopement risk/wanderer related to impaired safety awareness, noted that the resident wore a wander alert pendant, and was independent with mobility. Facility records showed conflicting information about the resident’s assigned household, with the Wanderguard list indicating the Life Bridges household and a resident list report indicating a different household.

The DON and ADON explained that the resident lived in the Life Bridges household and had gone out the north door of the facility, where the resident was usually supervised when outside. The DON stated that because the resident did not “actually elope,” the facility decided it was not necessary to document the incident in the clinical record. Upon later review, the DON acknowledged that staff are expected to document any incidents or unusual occurrences in the clinical record for all residents. The facility’s Nurse Competency Check Off List, reviewed on 6/24/24, required documentation of follow-up notes, family communication, hot charting, changes in condition, behaviors, new skin issues, unusual events, and alleged abuse, indicating that documentation of such incidents was an expected standard that was not followed in this case.