F0842

D

Inaccurate 15-Minute Check Documentation After Resident Elopement

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident who had physician orders and care plan interventions for every 15-minute monitoring. The resident had vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, chronic pain, a history of traumatic brain injury, poor impulse control, a history of altercations with another resident, and a history of alcohol abuse. The resident’s care plan identified impaired cognitive function and risk for disorientation, confusion, unsteady gait, and slurred speech, with interventions including every 15-minute monitoring. A physician’s order dated 1/23/26 directed that the resident be on every 15-minute observations every shift, and a nurse’s note on the same date documented that the resident expressed a desire to leave the facility and was placed on every 15-minute checks.

On 2/25/26, an LPN documented that upon returning to the unit at 1:55 PM, she was informed by a nursing assistant and a housekeeper that the resident was not in the room or on the unit. She checked the room and unit, notified the nursing supervisor, and a building-wide search was initiated. The last time she reported seeing the resident was at 1:00 PM. The DON later reviewed camera footage and identified that at 12:36 PM the resident was seen looking around the hallway, approaching the keypad, and exiting a secured door into the stairwell, then going down 4.5 flights of stairs and exiting through an unsecured door to the outside. Despite this, the every 15-minute check sheet for that date showed continuous documentation from 7:00 AM through 1:15 PM indicating the resident was present on the unit, including entries at 12:45 PM, 1:00 PM, and 1:15 PM.

Interviews revealed that the documentation on the every 15-minute check sheet was not based on actual observations. NA #2 stated she was not assigned to the resident on that shift and had not completed any 15-minute checks, but after the resident could not be located, the ADON directed her to fill out the sheet, and she did so despite knowing it was incorrect, estimating times for the checks. NA #3 reported that although her initials appeared as documenting on the resident for that shift, she did not complete any of the 15-minute checks due to a heavy assignment. The LPN confirmed that the ADON came to the unit, discovered the check sheet had not been filled out for the entire shift, and told NA #2 and the LPN they needed to figure out how to complete it. The ADON acknowledged directing staff to complete the sheet after the fact and stated the checks should have been documented at the time of observation. The DON confirmed that the clinical record should have been complete and accurate, that the resident was off the unit at the times documented as present, and that the documentation was therefore inaccurate and inconsistent with the facility’s policy requiring factual, objective, timely, and truthful entries, with late entries clearly identified as such.