Inaccurate and Incomplete Elopement Risk Documentation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident assessed and care planned for elopement risk and wandering. The resident was admitted with dementia, encephalopathy, hypertension, and osteoarthritis, and had a BIMS score of 03, indicating severe cognitive impairment. The admission MDS assessment documented that the resident had not exhibited wandering behavior, even though a care plan dated the following day identified a focused care area for elopement risk/wandering related to decreased cognition and decreased safety awareness, with multiple interventions such as redirection, diversional activities, structured activities, toileting, walking, and reorientation strategies. An evaluation summary entry dated the same day initially indicated that a wandering/elopement risk evaluation had been completed, but this note was later struck out. A wandering/elopement risk evaluation dated that same day was not signed and locked until several weeks later, after an incident in which the resident was found outside the facility at night by another resident’s family member, lying on her stomach and complaining of back pain, unable to move or roll over, and subsequently sent to the hospital. The evaluation summary and recommendations section included instructions to keep the door closed on the resident’s unit and to have the receptionist close the front doors when off duty so only staff could unlock them. Staff interviews revealed inconsistent understanding of the resident’s wandering risk: an LPN stated the resident was not considered at risk for wandering before the incident, though the resident had been anxious and expressed a desire to go home, and a CNA reported not observing wandering behavior. The DON confirmed that the struck-out wandering/elopement risk evaluation was incorrect because the resident was not considered an elopement risk at that time and that the elopement assessment was actually completed after the incident, contrary to the documentation. This conflicted with facility policy requiring the medical record to accurately represent the resident’s experiences and condition, including changes, plan of care goals, and interventions.
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