Inaccurate Documentation of Resident Elopement Attempts
Penalty
Summary
Facility staff failed to accurately document a resident’s elopement history in the clinical record and on multiple Elopement and Wandering Risk Observation/Assessment forms. The resident, admitted with schizoaffective disorder, dementia, and generalized anxiety disorder, had severely impaired cognition per an MDS dated 9/21/2025 and required supervision or touching assistance for ADLs. An SBAR dated 9/14/2025 documented that the resident was observed attempting to jump over a facility fence and was redirected by staff. However, on the Elopement and Wandering Risk Observation/Assessment form completed later that morning, the RN Supervisor recorded in the History of Elopement Attempts section that the resident expressed plans to leave but had not attempted to do so, omitting the documented elopement attempt from earlier that day. A subsequent assessment on 9/29/2025 by the MDS Coordinator again stated the resident planned to leave but had not attempted to do so, despite the prior documented attempt on 9/14/2025. An SBAR dated 11/2/2025 recorded another elopement attempt, describing the resident trying to climb over a fence behind the east building using a bedside table, with a CNA intervening and redirecting the resident. Later that morning, the ADON completed an Elopement and Wandering Risk Observation/Assessment form and again documented that the resident planned to leave but had not attempted to do so, failing to record the elopement attempts on 9/14/2025 and 11/2/2025. On 11/17/2025, the RN Supervisor completed another assessment form and again documented that the resident planned to leave but had not attempted to do so, omitting the two prior attempts. During interview, the DON stated that these Elopement and Wandering Risk Observation/Assessment forms were completed incorrectly and that they provided an inaccurate depiction of the resident’s history, contrary to the facility’s Charting and Documentation policy requiring objective, complete, and accurate documentation in the medical record.
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