Failure to Report Elopement and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report several significant incidents to the State Survey Agency as required by both facility policy and regulatory standards. Specifically, an elopement involving a cognitively intact resident with a history of wandering and delusional behaviors was not reported. The resident exited the facility, evaded staff supervision, and entered nearby woods, prompting a police search with dogs. Despite the seriousness of the event and the involvement of law enforcement, the incident was not reported to the appropriate authorities. Additionally, the facility did not report multiple resident-to-resident altercations, some resulting in injury or with the potential to cause injury. One resident with severe cognitive impairment and a history of physical aggression was involved in several altercations, including an incident where another resident was punched in the face, resulting in a busted lip. Other altercations involved residents being hit or jumped on, though no injuries were recorded in those cases. These incidents were documented internally but not reported externally as required. Interviews with the facility Administrator confirmed that these incidents were not reported to the State Survey Agency, despite facility policies mandating immediate reporting of abuse, neglect, and altercations. The facility's own policies specify that all such incidents, including resident-to-resident altercations, must be reported to the appropriate agencies. No additional documentation or evidence of reporting was provided by the facility during the survey.