Failure to Document Resident Elopement in Clinical Record
Penalty
Summary
The facility failed to maintain a complete clinical record for one resident following an elopement event. Facility policy on elopement, revised June 2023, required that after an elopement and upon the resident’s return, the DON or charge nurse complete and file an incident report and document the event in the resident’s medical record. The resident involved had diagnoses including alcoholic cirrhosis of the liver, hepatic encephalopathy, and GERD. On the evening of February 4, 2026, facility staff were unable to locate this resident at approximately 8:45 PM, and the resident was later found on the street about 0.3 miles from the facility at approximately 9:10 PM. An incident report dated February 4, 2026, contained a detailed description of the resident’s elopement, but the form was labeled at the bottom as “Privileged and Confidential–Not part of the Medical Record.” Review of the resident’s clinical record on February 9, 2026, showed no progress notes or any other documentation of the elopement event. During interviews, the Regional Director of Clinical Services stated that the nurse’s risk management note on the incident report should have populated into the clinical record progress notes, but a required button may not have been clicked, preventing the note from appearing in the clinical record. As a result, the resident’s medical record did not contain documentation of the elopement as required by facility policy and 28 Pa Code 211.5(f)(ii)(iii) regarding medical records.
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