Failure to Notify Resident Representative of Elopement and Fever
Penalty
Summary
Licensed nurses failed to notify a resident’s responsible party (RP) of significant changes in condition and status, including an elopement and a fever. The resident had dementia, bipolar disorder, a cognitive communication deficit, repeated falls, and an active order stating he was not capable of making his own health decisions, with his daughter listed as the RP and emergency contact. He also had an active order for a Wanderguard due to exit-seeking behavior. On 2/28/26, a change of condition note documented that the resident eloped from the facility sometime after he was last seen in bed at 4:00 a.m. and was found by police at a baseball field across from the facility and returned around 5:00 a.m. The note also indicated the Wanderguard was in place but did not alarm when the resident exited. There was no documentation that the RP was notified of this elopement. On 3/1/26, a progress note documented by a licensed nurse indicated a change of condition for fever, with the resident noted to be sneezing and congested, and temperatures of 100.4°F and later 101.1°F recorded, with acetaminophen administered and the MD notified for congestion medicine. There was no documented evidence that the RP was notified of the fever. In an interview, the RP stated she was not informed by the facility of the elopement and learned of it from a friend who heard the resident’s name on a dispatch call, and she later observed new coughing when visiting the resident. The DON stated she expected licensed nurses to complete change of condition reports for elopement and fever and to notify the RP, and confirmed there was no documentation of such notifications. One licensed nurse acknowledged she did not notify the RP of the fever because she did not know it was required. Facility policies on wandering/elopement and change in condition required notification of the resident’s legal representative or resident representative and documentation in the medical record when such events occurred.
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