Failure to Timely Report Elopements and Abuse Allegation
Penalty
Summary
The facility failed to report two elopements and an allegation of abuse to the State Agency in a timely manner for two residents. One resident, who was cognitively intact but identified as an elopement risk with a history of wandering, exited the building on at least two occasions. On one occasion, the resident was found alone outside, approximately 100 feet from the emergency exit, without her walker. Staff who witnessed the incident reported being instructed by the Nursing Home Administrator and Director of Nursing not to document the event in the electronic medical record. The incident was not reported to the State Agency, and there was no documentation or signed staff interviews related to the event in the resident's medical records. Another resident, with diagnoses including Alzheimer's disease and psychotic disorder, reported to her nurse that she had been inappropriately touched by a visitor. The facility's incident report indicated that the allegation of abuse was discovered in the evening and not reported to the State Agency until the following morning, exceeding the required two-hour reporting window. The former Nursing Home Administrator could not recall the details of the reporting process but confirmed that such allegations should be reported within two hours. Facility policy requires immediate reporting of abuse, neglect, or mistreatment to the State Agency, but in these cases, the required notifications were not made within the mandated timeframe. The lack of timely reporting and documentation resulted in the potential for ongoing mistreatment and unreported incidents.