Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled effective and efficient use of its resources to maintain the highest practicable well-being of each resident, specifically related to the failure of the Administrator and/or DON to notify the state regulatory office of an elopement incident. On 04/18/2025, a resident exited her room, traversed multiple doors, entered a staff area, and ultimately accessed the facility's loading dock, where she operated a lift and was elevated above the pavement. The facility's policies required reporting such incidents to the State Survey Agency, but this was not done. Interviews with the DON and Administrator revealed a lack of clarity and communication regarding the incident. The DON was not present at the time and, after being informed, recognized the event as an elopement but did not report it. The Administrator, also absent during the incident, initially did not consider the event an elopement and therefore did not report it, only acknowledging the requirement after regulatory review. Both the Administrator and DON's job descriptions included responsibilities for regulatory compliance and incident reporting, which were not fulfilled in this case.