Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The facility failed to report an incident of elopement involving a resident to the state survey agency (SSA) as required by their own policy and federal or state regulations. The resident, who had diagnoses of encephalopathy and anoxic brain damage, was admitted with a documented need for close supervision due to impaired cognition and poor safety awareness, and was identified as an elopement risk. On the day of the incident, the resident eloped while a licensed vocational nurse was temporarily assisting another resident. The facility initiated a search and notified the police, the resident's family, the director of nursing, and the administrator, but did not notify the SSA. Interviews with the director of nursing and the administrator confirmed that the elopement was not reported to the SSA, with the administrator stating the event was not reported because the resident was eventually found. Review of the facility's policy on Unusual Occurrence Reporting indicated that such events, which affect the health, safety, or welfare of residents, must be reported to appropriate agencies within 24 hours. The failure to report the elopement resulted in a delay in the investigation of the incident and in ensuring the resident's safety.