Failure to Implement Elopement and Abuse/Neglect Policies
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation and Elopements and Wandering Resident policy for a resident with a history of elopement. The resident, who had moderate cognitive impairment and was independent with activities of daily living, was observed wearing a wanderguard but reported having previously cut off the device and left the facility on multiple occasions. The resident described using a fingernail file to remove the wanderguard, leaving the facility undetected, and being found by police after walking a significant distance. The resident also stated intentions to elope again and described previous successful attempts, including one where he was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record revealed a lack of documentation regarding the reported elopement attempts. Facility incident reports did not include any risk management, incident reports, or investigations related to these events. Additionally, the state agency's reporting center had no record of facility-reported incidents for the resident's elopement attempts. Interviews with staff confirmed awareness of the resident's elopement risk and recounted the events of the most recent elopement, including the resident being found by police far from the facility. Staff also noted the resident's pattern of waiting for opportunities to leave undetected. Despite the facility's policy requiring immediate investigation and reporting of suspected neglect or elopement, the incidents were not investigated or reported to the state agency. The DON and administrator both indicated that they did not consider the events to be elopements and therefore did not initiate investigations or reporting, even though the resident had left the facility without staff knowledge. The facility's policy outlines specific procedures for investigation, documentation, and reporting, none of which were followed in these instances.