F0842

D

Failure to Accurately Document Resident Elopement and ER Visit in Medical Record

Fort Myers, Florida Survey Completed on 02-13-2026

Penalty

Fine: $17,675

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who eloped from the facility and was sent to the emergency room. Facility policy required that nurse’s notes be written by licensed/qualified nursing personnel, address the resident’s condition, be specific and objective, and be signed with the writer’s name and credentials, with frequency of entries based on resident need and changes in condition. The resident was admitted in early November and had an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Nursing progress notes documented the resident’s level of consciousness and orientation on the evening of one date, with the next note two days later, but there was no documentation in the clinical record of the resident’s elopement, emergency room visit, or return to the facility.

Interviews and external records confirmed that on a late November morning the resident exited the facility without staff knowledge or supervision, walked to a nearby state college dormitory, and was found there confused, disoriented, unsteady, and shaking. Campus personnel contacted EMS, which transported the resident to a local emergency room, with EMS records documenting times of response, departure, and transfer. The DON and Administrator verified the elopement and lack of documentation in the clinical record, and a unit manager stated she had been told not to document anything about the incident in the record, believing the DON and Administrator would handle it. The Administrator reported that a BIMS test was administered upon the resident’s return, but the provided BIMS form was unsigned and lacked the writer’s credentials, further contributing to the incomplete and noncompliant documentation of the resident’s medical record.