Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to notify the State Survey Agency of an incident of elopement within the required two-hour timeframe. This deficiency was identified through a review of clinical records, incident reports, and staff interviews. The incident involved a resident who left the facility without authorization. The resident, who had a history of opioid abuse, alcohol abuse, psychoactive substance abuse, and cerebral infarction, was observed leaving the facility and heading towards a bus stop. Despite efforts by staff to locate the resident, including searching the area and attempting to contact the resident via a listed phone number, the resident was not found. The facility's policy on investigating and reporting accidents and incidents requires that all incidents involving residents be reported to the administrator. However, the facility did not complete an incident report or notify the State Survey Agency within the required timeframe. This lapse was confirmed by the Regional Clinical Specialist, who acknowledged the failure to report the elopement incident involving the resident.
Plan Of Correction
0008 Notification 1. The required notification time period for this incident cannot be corrected. 2. Department of Health Event Reports for the past 30 days will be audited by the Administrator or designee against the required reporting time periods to determine the level of compliance. 3. The Administrator and Director of Nurses will be educated on regulation H-0008 by the Regional Clinical Specialist or designee. The Department of Health Event Reports will be audited for compliance with the correct time periods daily for 3 weeks and then monthly for 2 months. 4. Audits will be reviewed in the monthly QAPI meetings for 2 months.