Failure to Notify Family of Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member when the resident eloped from the facility. The resident was admitted with diagnoses including Wernicke’s encephalopathy and had a family member listed as emergency contact number one. An elopement and wandering risk assessment indicated the resident was alert and oriented to person, place, and time and able to follow instructions. Nursing notes documented that on the evening in question, the resident was alert, oriented to two spheres, able to follow commands, and ambulatory with a cane. The resident was last seen at the nurses’ station around 6:30 p.m. and later in the lobby doing word search puzzles, and then was noted to be missing from his room at approximately 8:50 p.m., prompting a facility-wide search and activation of the facility’s missing resident code. When the resident could not be located within the building or on the grounds, staff initiated external search efforts, and the charge nurse notified law enforcement and the physician. However, the charge nurse did not notify the resident’s family member at that time, despite the facility’s policy requiring family/responsible party notification when a resident is not found in the facility or on the grounds. Interviews later confirmed that the LVN did not contact the family because staff were still looking for the resident, and the LVN acknowledged the family should have been notified. The RN stated she had asked the LVN to call the family, and the DON stated that the RN or LVN is responsible for notifying the family and documenting it in the record. Documentation showed that social services did not attempt to contact the family until the following day, nearly 15 hours after the resident was first noted missing, at which time the family reported the resident was at a general acute care hospital. This sequence of events demonstrates that the facility did not follow its own emergency procedure for missing residents regarding timely family notification.
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