Failure to Timely Report Elopement Incident
Penalty
Summary
The facility failed to timely report an elopement incident involving a resident, identified as R89, to the State Agency (SA). R89, who has dementia and is unable to make medical decisions, was found outside the facility by a CNA, identified as CNA H, on their last working day. The CNA brought the resident back inside but did not report the incident according to the facility's protocol. The Director of Nursing (DON) and the Administrator were informed of the incident on 3/30/25, but the incident was not reported to the SA until 4/3/25. The facility's investigation into the incident was delayed and incomplete. The Administrator and Nurse Consultant A were unable to provide a complete investigation report or an Incident and Accident report when requested by surveyors. The facility's documentation was inconsistent, with a corrective action for CNA H being backdated and not accurately reflecting the follow-up actions taken. The Administrator admitted to errors in the report submitted to the SA, which inaccurately described the surveyors' findings. The facility's policy on elopements, which requires prompt reporting and documentation of such incidents, was not followed. The lack of timely reporting and accurate documentation of the elopement incident led to a deficiency being cited during the survey. The facility's failure to adhere to its own policies and procedures contributed to the deficiency identified by the surveyors.