Incomplete Documentation and Missing Orders for Placement on Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and professionally accurate medical records for two residents placed on a secured memory care unit. For the first resident, a female with Alzheimer’s disease and dementia, documentation showed an initial elopement risk assessment indicating no history of elopement or attempts to leave home or the facility, no verbalization of wanting to go home, and no wandering with a specific destination. Her quarterly MDS documented severely impaired cognition with a BIMS score of 0 and no behaviors, and nurse notes over several weeks showed no exit-seeking behaviors. Although her care plan identified risk for wandering/elopement with interventions, there was no physician order in the January orders for placement on the secured unit, and no documentation in the record of elopement behaviors prior to her transfer, despite staff interviews stating she had been moved to the secured unit a few weeks earlier due to exit-seeking behaviors. For the second resident, who had dementia and moderately impaired cognition with a BIMS score of 8, an elopement risk assessment initially indicated no history of elopement or attempts to leave home or the facility, and no verbalization of wanting to go home or packing belongings to leave. Nurse notes documented increasing agitation, restlessness, paranoia, refusal of medications, and statements that staff were trying to poison her or keep her like a prisoner, as well as concerns about family and money. A subsequent elopement risk assessment documented that she had been seen packing belongings to go home without a discharge plan. Nurse notes recorded that she was moved from another hall to the secured unit, with the responsible party notified and the resident tolerating the room change. Her quarterly MDS still reflected no behaviors, and January physician orders contained no order for placement on the secured unit, even though her care plan identified her as at risk for elopement with a history of attempts to leave and wandering. Interviews with administrative and nursing staff confirmed that facility policy required residents placed on the Memory Care (secured) unit to meet specific criteria, be assessed by the interdisciplinary team, have documentation in the clinical record supporting elopement risk, obtain physician orders for placement, and involve the resident’s representative. The Memory Care Program policy stated that admission to the secured unit must be based on interdisciplinary assessment of cognitive and functional status, a determination of need for a safer environment or wandering/elopement risk, and approval by the IDT, with the patient representative contacted regarding placement. Staff, including the administrator and nursing personnel, acknowledged that there should be documentation and a physician order for placement on the secured unit, and that without such documentation the record would be incomplete. Despite this, both residents were observed residing on the secured unit without corresponding physician orders or complete supporting documentation in their medical records.
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