Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to notify the Department of Health of six out of seven reportable elopement events involving a resident. The resident, who was admitted with diagnoses including high blood pressure, dementia, and cerebral infarction, was involved in multiple incidents where they were found outside their designated area. These incidents occurred over a period of time and included the resident being found on different floors and areas of the facility, such as near the kitchen and at the reception desk. Despite these occurrences, the facility did not report these elopements to the appropriate agency as required by regulation. The resident was assessed as being at high risk for elopement, as indicated by an Elopement Evaluation score. The facility's policy required that any accidents or incidents involving residents be reported to the physician and responsible party within twelve hours, but this protocol was not followed in terms of notifying the Department of Health. The Nursing Home Administrator and Director of Nursing confirmed the failure to report these events, which seriously compromised quality assurance and patient safety as outlined in the regulatory requirements.
Plan Of Correction
The facility reported the elopement to the DOH on 4/5/25. The facility developed an Event Reporting Policy that includes an outline of the incidents and events that are required to be reported per Chapter 51.3. The facility updated its Change in Condition Policy to include elopement incidents and the required reporting and follow-up. All departments (Agency and staff) were educated about elopement risks and procedures, that included recognizing elopement and reporting of elopement incidents immediately to their immediate supervisor and then the Nursing Home Administrator and Director of Nursing. This education will also be included in the new hire curriculum and at least annually with all staff education days. The Elopement Prevention Audit Tool, which includes physician orders, treatment record documentation, elopement binders, incident reports, hourly logbooks, event reporting, and physician notification is being completed by the DON or designee daily for 2 weeks starting on 4/16/2025, then weekly for 3 weeks, then monthly for 3 months, and then quarterly thereafter with the results reported to the Quality Assurance Committee for further follow-up. Completion date - May 16, 2025.