Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident, identified as Resident R456, who eloped from a locked unit. The facility's policy requires that all unusual occurrences, such as elopements, be documented with an incident report and that an investigation be conducted, including obtaining witness statements. However, the investigation into Resident R456's elopement did not include any witness statements, which is a critical component of a thorough investigation. Resident R456 was admitted to the facility with a history of malignant neoplasm of the brain, metabolic encephalopathy, and a mood disorder due to a physiological condition. The resident was assessed with a BIMS score indicating moderate cognitive impairment. On the date of the incident, the police were involved in a preliminary search for the resident, but the facility's investigation was incomplete as it lacked necessary witness statements. The Director of Nursing confirmed the failure to fully investigate the incident to rule out neglect.
Plan Of Correction
1. The facility is unable to retroactively correct the deficiency as it relates to R456, who is no longer a resident in the facility. 2. An audit will be done by the director of nursing of all investigations conducted in the last 30 days to ensure witness statements were collected. 3. The director of nursing or designee will in-service the nursing leadership team on collecting witness statements for unusual occurrences concerning residents to rule out neglect. 4. The director of nursing or designee will audit all investigation files for 4 weeks to ensure witness statements have been obtained as appropriate. Audit findings will be shared with the QAPI committee.