Failure to Report, Investigate, and Document Resident Elopement
Penalty
Summary
The facility failed to report, investigate, and document an incident of resident elopement in accordance with federal regulations. A resident with severe cognitive impairment and multiple medical conditions, including alcohol-induced dementia and a history of falls, exited the building unsupervised and was found outside the facility in a hospital gown, pushing a wheelchair. Despite this, the Director of Nursing (DON) initially denied any elopement had occurred and only acknowledged the incident after further questioning. The Nursing Home Administrator (NHA) also did not consider the event to be an elopement and was unable to provide evidence regarding the resident's whereabouts or the duration of time spent outside unsupervised. Additionally, the facility's security camera system was not functional at the time of the incident. Staff interviews revealed that the incident was not properly documented or investigated. The LPN initially recorded the event as an attempted elopement and did not update the documentation after learning the resident had actually left the building. The DON confirmed that no investigation was conducted until prompted by the surveyor's inquiry. The facility's elopement policy requires completion and filing of an incident report when a resident leaves the facility, but this was not followed. The receptionist desk was also left unmanned during breaks, potentially contributing to the lack of supervision.