Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to immediately report an elopement incident involving a resident with dementia, delirium, and a history of falls. The resident, who required supervision for transfers and had severe cognitive impairment, was identified as being at risk for elopement and had interventions in place, including a Wanderguard device. Despite these measures, the resident was found wandering outside the facility, and it was noted that the Wanderguard alarm did not activate when the resident exited, though it did sound upon re-entry. The incident was documented in the resident's progress notes and incident report, which indicated confusion and impaired memory as contributing factors. The nurse on duty did not report the elopement to the on-call nurse, administrator, or DON immediately after the event. The incident was not reported to the state agency until the following day, exceeding the facility's policy requirement to report such events to the administrator and state agency within two hours. Facility policies reviewed confirmed the expectation for immediate reporting of elopements and potential neglect, but these procedures were not followed in this case.