Failure to Timely Report Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the State Survey Agency within the required timeframe. Specifically, an incident occurred in which a male resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk, exited the facility undetected during the night. The resident, who was wearing a Wanderguard device as per physician order, was found at an apartment complex across the street and returned to the facility with minor injuries. Documentation showed that the resident's Wanderguard was checked regularly and was reported to be in working order, but there were missing timestamps for checks on the days surrounding the incident. The facility's records did not indicate that an elopement evaluation had been completed prior to the incident, and the event was not reported to the State Survey Agency within 24 hours as required by policy and regulation. Interviews with staff and the resident's family revealed that the facility was not aware of the resident's prior history of elopement before admission, as this information was not solicited or provided during the pre-admission process. The family was notified of the incident by an outside party, and the facility staff only became aware of the resident's absence after being contacted. The Administrator and ADON were both on leave at the time of the incident, and the DON was responsible for reporting the event. However, there was no confirmation or documentation that the required self-report was made to the State Survey Agency, and the incident report was not uploaded to the TULIP system. The Administrator later acknowledged that she did not follow up to ensure the report was submitted, relying on the DON's verbal assurance. Facility policies required immediate reporting of all alleged violations involving abuse or neglect, including elopement incidents, to the appropriate authorities. The policies also outlined procedures for staff to follow in the event of a missing resident, including notification of the Administrator, completion of incident reports, and documentation in the medical record. Despite these policies, the failure to report the elopement incident within the mandated timeframe constituted a deficiency in the facility's abuse and neglect reporting procedures.