Failure to Investigate Resident Elopement from Facility
Penalty
Summary
The facility failed to investigate and determine how a resident with a history of schizophrenia, anxiety disorder, and moderately impaired cognitive skills was able to leave her room unattended and was subsequently found in the facility's parking lot. The resident had been assessed as having intermittent confusion, was ambulatory, and was identified as being at risk for elopement. Despite these risk factors, there was no documentation or investigation into how the resident exited her room and reached the parking lot. Interviews with facility staff, including security guards, an LVN, the DON, and the administrator, confirmed that the resident was found outside on facility property, but none could explain how she left her room. The incident was not documented, and no investigation was conducted because the resident was found within the facility's property. The facility's policy requires individualized safety measures and analysis of risks, but these procedures were not followed in this case.