Failure to Report Resident Elopement
Penalty
Summary
The facility failed to notify the local State Agency of a reportable event in a timely manner involving a resident who eloped from the facility. The resident, who had been admitted with diagnoses including degeneration of the nervous system due to alcohol, diabetes mellitus, and epilepsy, was found in the parking lot in her wheelchair by a nurse aide. This incident occurred on 11/24/24, but the facility did not report the elopement to the State Agency field office within the required timeframe. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the resident had eloped through the lobby front doors to the parking lot. A review of reports submitted to the local State field office between 11/24/24 and 12/2/24 showed no notification of the elopement event, indicating a failure in the facility's reporting procedures for serious incidents that compromise patient safety.
Plan Of Correction
1. Facility notified the local state agency of the reportable event for Resident R1 on December 5, 2024 after recommendation by local state survey. 2. The Director of Nursing will be educated by Regional Director of Clinical Support on timely event reporting. 3. The Director of Nursing/designee will audit all events for reporting criteria daily for 2 weeks during morning meetings, weekly for 2 weeks, and monthly for 2 months. Audit results will be reviewed at monthly QAPI meetings.