Inaccurate Documentation of Resident Elopement Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who left the building and was later found in the road. A progress note dated 3/2/26 at 10:30 AM, written by the DON, documented that the resident had an “attempted elopement” and was “intercepted,” and that reorientation to her situation was attempted without success. However, during interview, the DON stated that on the morning of 3/2/26, while management staff were in a morning meeting, a visitor entered the conference room and reported that a resident was outside. Management staff immediately left the meeting and located the resident on the road just past the gravel parking lot. The DON described the resident’s mentation as altered and “manic,” and reported that she was difficult to convince to return to the facility as she continued to try to propel her wheelchair further up the hill, stating she needed to take care of her son. The DON acknowledged in interview that the resident did in fact elope and was found down the road below the gravel parking lot, and he was unable to explain why he had documented in the progress note that the elopement was only attempted and that the resident was intercepted by staff. In a separate interview, the Administrator confirmed that during the same morning meeting a visitor reported a resident in the road, and that staff then caught up to the resident, who was across the road from the facility, just past the gravel parking lot, sitting in her wheelchair in the road. The Administrator stated the resident had exited via a side door and expressed uncertainty as to why all staff did not know the resident had actually gotten out of the building. The Administrator also questioned why the DON’s progress note characterized the event as an attempted elopement and stated that she expected all information entered into a resident’s medical record to be accurate.
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