Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an elopement incident involving a resident diagnosed with dementia, who was found outside the facility. The resident, who was unable to make medical treatment decisions and had an activated power of attorney, was discovered by a CNA outside the facility under the awning. Despite the incident occurring, there was no documentation in the resident's medical record about the elopement, and the facility did not follow its policy to investigate and report the incident. The Director of Nursing (DON) and the Administrator were informed of the incident, but there was a delay in initiating a thorough investigation. The CNA who found the resident outside reported the incident to other staff members, but there was no follow-up or documentation of the event in the resident's medical record. The facility's investigation file lacked a narrative of the incident, findings, root cause identification, and accountability or supervision issues related to the staff assigned to the resident. The facility's policy on elopements, which requires staff to investigate and report all cases of missing residents, was not followed. The Administrator and corporate staff failed to provide a complete investigation or an Incident and Accident report to the surveyors by the end of the survey. Additionally, the facility's camera footage, which could have provided more information about the incident, was not available for review as it was only kept for 24 hours.