Failure to Fully Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to fully investigate an incident involving a resident who was at risk for elopement and was found outside the facility without staff awareness. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was rarely able to understand or be understood and had been identified as an elopement risk in the care plan. Despite this, there were no physician orders related to wandering or elopement risk, and documentation of the resident's wandering history was inconsistent. On the day of the incident, the resident was discovered outside the building on the road, interacting with a passerby, and was subsequently returned to the facility and sent to the emergency department for evaluation. The facility's investigation into the incident was incomplete, as it failed to gather a statement from the Environmental Services (EVS) employee who had silenced the alarm without ensuring no residents were present in the stairwell. The DON and Nursing Home Administrator later confirmed that the investigation did not include an interview with this key employee, and the surveyor's interview with the EVS employee contradicted the facility's initial findings. This lack of a thorough investigation prevented the facility from eliminating possible neglect in the incident.