LPN #1 was covering medication duties for another nurse who had gone on break when Resident #2 complained of a headache around 2:30 PM. When she went to give the resident Tylenol, the room was empty.
"She checked the hallway and did not find the resident, so she paged all staff to come to the First-Floor nursing unit," according to the October 29 inspection report from Excel Care at Wayne.
A family member of another resident spotted the missing person outside wearing sleepwear. LPN #1 and other staff members "ran outside and ran for about 1-2 minutes" before finding another family member sitting by the facility's gazebo who pointed them toward the street.
They found the resident standing on the sidewalk a block away with two women who said the resident looked out of place in sleepwear.
The resident was brought back inside and assessed by the assigned nurse, LPN #3, who found no injuries. But no one documented the elopement in the medical record.
During interviews eight days later, facility administrators confirmed the documentation failure violated professional standards.
When asked what should be documented in residents' medical records, the Director of Nursing listed "falls, wounds, changes in status, medication changes, appointments, and behaviors."
The Vice President of Clinical confirmed that elopement "would be" considered a behavior and "technically should have been documented in the resident's medical record."
LPN #1 told inspectors during a follow-up interview that she was responsible for documenting the incident since LPN #3 had stepped away for five minutes. She confirmed "there should have been a Progress Note that included the resident's elopement on 10/19/2025, so other staff were aware the resident had eloped."
"Charting was usually done on post incidents, and that this was an incident that should have been documented," LPN #1 said.
Inspectors attempted to interview LPN #3 by telephone on October 29 but she didn't answer and never returned the call. She wasn't present during the survey.
The facility's own nursing documentation policy, dated May 1, 2025, requires staff to document "all nursing interventions and observations, including but not limited to changes in condition or behavior."
The policy emphasizes that "documentation should occur promptly" and provides "a clear, consistent record of care" that "facilitates communication among care team members, and ensures continuity of care for residents."
Without documentation of the elopement, other staff members working future shifts would have no knowledge that the resident had previously wandered outside unsupervised.
The resident's medical record contained routine assessments noting normal skin color and turgor, but made no mention of the incident that required multiple staff members to search the neighborhood and involved strangers finding the resident on a public sidewalk.
The documentation failure occurred despite the facility's policy requiring "accurate, timely and legally compliant documentation practices" and mandating that nurses "write concise, chronological notes on the resident status, interventions, and outcomes."
Excel Care at Wayne received a minimal harm citation for the violation, which affected few residents but highlighted gaps in the facility's incident reporting procedures.
The case demonstrates how documentation failures can compromise resident safety by preventing care teams from identifying patterns of behavior or implementing appropriate interventions for residents who may be at risk of wandering.
State regulations require nursing homes to maintain comprehensive medical records that accurately reflect each resident's condition and care. The missing documentation of a resident found wandering outside in sleepwear represents a clear violation of these standards.
The two women who found the resident standing on the sidewalk immediately recognized something was wrong, noting the person looked out of place in sleepwear during the afternoon. Their quick thinking in staying with the resident until staff arrived likely prevented a more serious outcome.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Excel Care At Wayne from 2025-10-29 including all violations, facility responses, and corrective action plans.