Failure to Report Unauthorized Departures and Elopement
Penalty
Summary
The facility failed to timely report incidents involving three residents who left the facility without authorization. One newly admitted resident eloped during a smoke break, while two other residents left the facility—one on a pass and did not return, and another left alone despite having an active physician order prohibiting unsupervised passes. The administrator confirmed that the police were contacted regarding the missing residents, but also stated unawareness of the requirement to report missing residents to the State Agency. Documentation revealed that the facility did not complete or submit incident reports for these events as required by their own policy, and the reportable binder contained no records of these incidents. Interviews and record reviews indicated that staff were aware of the residents' absences and communicated internally, but failed to follow through with external reporting obligations. Nursing notes and sign-out sheets documented the residents' departures and lack of return, but there was no evidence of timely notification to the State Agency. Additionally, the medical chart for the resident who eloped lacked an elopement assessment or care plan. The facility's policy requires all accidents or incidents to be investigated and reported to the administrator, with incident reports to be completed and submitted to the DON within 24 hours, which was not done in these cases.