Failure to Notify Legal Guardian of Resident Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal guardian of an elopement incident as required by facility policy. The resident, admitted with diagnoses including anxiety, chronic kidney disease, type 2 diabetes, cognitive communication deficit, Parkinson’s disease, and dementia without behavioral disturbance, had a daughter listed as his legal guardian. A discharge, return-anticipated MDS assessment indicated his memory was intact, he did not wander, and he required partial to moderate assistance for ambulation using a wheelchair. On the date of the incident, a progress note by an RN documented that the resident pushed on an exit door, triggering the alarm, and was found on his right side on the ground with his wheelchair beside him after an unwitnessed fall. A head-to-toe and neurological assessment were completed, vital signs were obtained, and the resident was assisted back into his wheelchair and brought to the nursing station for closer monitoring. A facility investigation documented that the resident had exited through an emergency exit door off a hall under construction and not occupied, had been outside less than five minutes, and had last been seen at the nurses’ station five minutes prior. The investigation noted that the alarm and egress doors functioned properly and staff responded immediately, finding the resident on the ground outside. However, the resident’s medical record did not contain evidence that the legal guardian was notified of the elopement. During a telephone interview, the guardian stated she had only been notified of the fall and was not aware the resident had gotten outside until speaking with the surveyor. The DON reported that an incident report in risk documentation (not part of the medical record) showed the family had been notified of an incident and transfer to the hospital, but it was unclear whether this referred to the elopement or the fall. The facility’s policy required nursing staff to notify the resident’s representative when the resident was involved in any accident or incident resulting in injury or a significant change in condition, and this notification specific to the elopement was not documented.
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