Failure to Report Resident Elopement as Potential Neglect
Penalty
Summary
The facility failed to report a potential incident of neglect involving one resident who eloped from the facility without staff knowledge. The incident occurred when the resident, who was new to the facility and had a history of elopement from a hospital, climbed over the patio enclosure fence during an activity. The facility notified the resident's family and the police after discovering the resident was missing. The resident was later found unharmed and was with his son. However, the facility did not submit an incident report to the State Agency (SA) as required by their policy and federal and state law. A review of the resident's electronic health record showed the individual had multiple diagnoses, including hemiplegia and a history of stroke, and had not completed the 5-day Minimum Data Set due to the early departure from the facility. The facility's investigation report confirmed that while the family and police were notified, the SA was not informed of the incident. The Nursing Home Administrator acknowledged the failure to report the incident to the SA, stating it was overlooked after the resident was found safe.