Failure to Document Elopement Incident and Complete Quarterly Elopement Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and timely documentation related to an elopement incident and to follow its own policies for elopement risk assessment. Facility policy on documentation required nursing documentation to be concise, clear, pertinent, accurate, and to communicate the resident’s status and provide an accurate accounting of care and monitoring. A separate policy on resident elopement required that residents be reassessed at least quarterly for elopement risk. One resident, admitted with diagnoses including paranoid schizophrenia, diabetes, and hypertension, eloped from the facility on 2/26/26. However, the clinical record progress notes contained no documentation of the elopement event, the resident’s safe return, or notification of the physician and/or resident representative. Review of the resident’s elopement risk assessments showed they were completed on 1/14/25, 4/17/25, and 2/26/26, with no evidence that these assessments were performed on a quarterly basis as required by policy. During interviews, the DON confirmed that the clinical record lacked documentation of the elopement, the resident’s return, and required notifications, and stated that a risk management entry and/or progress note should have been completed. The DON and RNAC reported they were unsure how often elopement risk assessments were to be completed, and the NHA was also unable to verify the required frequency at the time of interview. The NHA confirmed that the resident’s record lacked evidence of quarterly elopement risk assessments, resulting in noncompliance with state regulations governing medical records and nursing services.
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