Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to report an incident of elopement involving one resident who was found outside the building unsupervised. Interviews revealed that the Director of Nursing (DON) initially denied any elopement had occurred, stating the resident had only attempted to elope. However, further interviews with staff confirmed that the resident had exited the building and was found outside in a hospital gown, pushing a wheelchair. The Nursing Home Administrator (NHA) did not consider the incident to be an elopement because the resident did not leave the premises, and was unable to provide evidence regarding where the resident was found, how the resident exited, or the duration the resident was outside unsupervised. The incident was not documented or investigated until prompted by a surveyor, and the family was not notified until several days after the event. The resident involved had a history of significant medical issues, including a fracture of the right femur, history of falls, alcohol dependence with alcohol-induced dementia, osteoporosis, chronic kidney disease, glaucoma, and sarcopenia. The Minimum Data Set indicated severe cognitive impairment. The facility's elopement policy defined elopement as a resident who needs supervision leaving a safe area without authorization and required an incident report to be filed if a resident leaves the facility. Despite this policy, no incident report or investigation was completed at the time of the event, and the facility failed to notify the family or authorities in a timely manner.