F0580

D

Failure to Notify Physician of Elopement Behaviors Before Discontinuing Dementia Diagnosis

Dallas, Texas Survey Completed on 02-06-2026

Penalty

Fine: $12,740

Summary

The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition related to repeated elopement behaviors when requesting discontinuation of the resident’s dementia diagnosis. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and had a documented history of psychiatric conditions such as schizophrenia, depression, anxiety, cognitive impairment, and high-risk behaviors including elopement. His care plan, initiated and revised in October and November, identified him as at risk for elopement, having impaired cognitive function/dementia, and requiring Donepezil for dementia. Despite this, on a late November date, the Resident Nurse Coordinator (RNC) struck out dementia as a primary diagnosis, and it no longer appeared on the face sheet. The RNC later stated she removed the dementia diagnosis because of a high BIMS score and nursing assessments, and reported that the MD said it was acceptable to discontinue the diagnosis.

The resident’s record showed multiple episodes of exit-seeking and elopement-like behavior. Progress notes documented that on one October date, security called nursing staff because the resident was at the gate wanting to go home; he was ambulatory with a walker and had to be redirected back into the building, after which he was placed on two-hour monitoring. On an early November date, notes described two episodes of elopement from the facility, aggression and combativeness when he was prevented from leaving, statements that he was being held hostage, inability to articulate a destination, involvement of police to control behavior, and transfer to a psychiatric hospital. Family members reported that the resident had a long-standing pattern of leaving facilities and psychiatric hospitals independently, often checking himself out or attempting to leave, and that this behavior had occurred at multiple prior settings. They also stated he had records of a dementia diagnosis, wore a medical bracelet listing dementia and stroke, and that he sometimes contacted them after leaving before the facility did.

Elopement risk evaluations and documentation in the record were inconsistent with the resident’s behaviors and abilities. An October elopement risk evaluation identified him as a moderate risk, cognitively impaired, ambulatory, and potentially going outdoors but not leaving the grounds. Subsequent evaluations in November were locked as “No Risk,” with staff only completing the “No Risk” section and not answering triggered questions for moderate or imminent risk, resulting in the system not classifying him as higher risk. These evaluations also contained discrepancies about his decision-making ability and ambulation status. Psychiatry/therapy notes from November indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, endorsing decreased concentration, forgetfulness, and ADL difficulties, and receiving Donepezil for cognitive symptoms. During interview, the MD confirmed he approved discontinuation of the dementia diagnosis based solely on the reported BIMS score, stated he was not aware of the resident’s exit-seeking or elopement behaviors, and noted there was no documentation of such behaviors in his or the NP’s notes. Facility policies required physician notification for changes in condition and for elopement events, but the MD’s lack of awareness of the resident’s elopement behaviors at the time the dementia diagnosis was discontinued demonstrated that the facility failed to ensure the physician was properly informed of these significant changes.

Additional documentation and interviews further highlighted the disconnect between the resident’s documented behaviors and the information provided to the physician. A late November progress note described the resident as aware of his needs, able to make decisions regarding his care and safety, and independently checking himself into a local hospital, characterizing this as consistent with his baseline pattern and as evidence of preserved decision-making capacity. This narrative contrasted with psychiatric documentation of cognitive impairment and with family statements that he could not make decisions for himself and had dementia. The Administrator later stated that he did not consider the resident’s departures to be elopements because of the high BIMS score and belief that the resident could make his own decisions, and he did not report the events as elopements. The DON and other staff reported that they had been in-serviced on elopement, exit-seeking behaviors, and the need to notify the physician, and facility policies on wandering and elopement required physician notification when a resident was missing and upon return after leaving without proper procedures. Despite these policies and the documented episodes of exit-seeking and elopement-like behavior, the MD was not informed of these behaviors when the dementia diagnosis was discontinued, resulting in the identified deficiency.

The facility’s Medical Record Content policy required accurate, timely documentation and prompt physician notification of changes in condition and unusual occurrences involving the resident, including documentation of attempts to notify the physician. The wandering and elopement policy required assessment of elopement risk upon admission, quarterly, and with changes in condition, and mandated physician notification when a resident could not be located and upon return after leaving without following proper procedures. In this case, the resident’s repeated attempts to leave, documented episodes involving security and police, transfer to a psychiatric hospital, and independent check-in to a local hospital were not fully or consistently reflected in the elopement risk evaluations or in communications to the physician. The MD’s statement that he was unaware of the resident’s exit-seeking and elopement behaviors at the time he agreed to discontinue the dementia diagnosis, combined with the facility’s own policies requiring such notification, formed the basis of the deficiency for failure to ensure the physician was notified of significant changes in the resident’s condition related to elopement behaviors.