Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an incident involving a resident's elopement in a timely manner to the New York State Department of Health. The resident, who had impaired cognition due to dementia and schizophrenia, was identified as being at risk for elopement. Despite this, the resident left the facility undetected on a busy holiday week day. The facility staff did not realize the resident was missing until dinner time, several hours after the resident had left. The incident was not reported to the state agency until the following day, which was beyond the required two-hour reporting window. The facility's policy requires that all occurrences of accidents or incidents be evaluated and investigated, with the Director of Nursing and Administration responsible for determining if an incident requires reporting to outside agencies. In this case, the investigation revealed that the resident exited through the front door during a high traffic period while the reception staff was occupied. The facility determined that there was reasonable cause to believe that abuse, neglect, exploitation, or mistreatment may have occurred, making the incident reportable. However, the delay in reporting the incident constituted a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 The elopement incident for resident # 1 was reported on 11/27/24. All facility DOH reportable events have the potential to be affected by this deficient practice. All DOH reported incidents were reviewed for the past 30 days. Facility policy on Accident/Incidents was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy of Accident and Incidents and timely reporting requirements. The in-service will focus on reporting incidents to the Administrator and DON immediately, reporting requirements of 2 hours to the DOH for reportable events. The Administrator/designee will audit all reported incidents for compliance with the 2-hour reporting time frame. The audits will be completed weekly x 4 weeks, then monthly until compliance is met. The results of these audits will be submitted at monthly QAPI to the committee for review. The administrator is responsible for the execution of this plan of correction.