Failure to Report Elopement and Neglect Incident to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of neglect and an incident of elopement involving one resident were reported to the appropriate agencies, including the State Agency, as required by state and federal law. On the date of the incident, a resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The resident was missing for approximately fifteen minutes before being found by a CNA sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard with no barrier or crosswalk. The resident was then escorted back into the facility. Facility records, including the accident/incident log and progress notes, showed that the event was not documented as an elopement, and no incident report was completed. The progress notes indicated that the Unit Manager, DON, Social Worker, and Executive Director were notified of the incident. However, the Executive Director determined that the event was not an elopement because the resident stated she was waiting for her brother, despite the facility's policy requiring anyone taking a resident out to sign them out at the nurses' station. No one had signed the resident out or made arrangements for her to leave, and the resident had exited the building with a group of nursing students without staff knowledge. Interviews with staff confirmed that the incident was not reported to the State Agency or other required authorities at the time. The Executive Director, DON, and Receptionist all acknowledged awareness of the incident but did not initiate the required reporting procedures. The facility's policies on abuse prevention, missing residents/elopements, and investigation and reporting of violations all require immediate reporting of such incidents to the appropriate authorities, which was not followed in this case.
Removal Plan
- The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
- The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
- An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
- A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
- The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
- Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
- The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
- 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
- An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.