Failure to Timely Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to timely report an incident of elopement involving a resident with a history of hallucinations and dementia. The resident, who was cognitively intact at admission with a BIMS score of 15, was last seen inside the facility at approximately 4:00 AM and was later found unsupervised in the facility parking lot by dietary staff at around 4:30 AM. Facility staff were unaware that the resident had left the building through an alarmed door, and staff did not investigate the audible alarm when it sounded. The resident reported feeling threatened by a nurse, which prompted her to leave the facility, and she was found outside by a staff member arriving for work. Despite the incident, the facility did not report the elopement to the State Agency until two days later. Interviews revealed that the LPN on duty heard the alarm but did not investigate, and the Administrator was not fully informed of the circumstances until returning to work after the weekend. The Director of Nursing was also unaware of the incident until after the State Agency began its investigation. The delay in reporting and lack of immediate investigation into the alarm and the resident's whereabouts constituted a failure to follow the facility's policy on incident investigation and reporting, which requires timely reporting of elopements and other reportable incidents. The deficiency was determined to be Immediate Jeopardy and Substandard Quality of Care, as the delay in reporting and failure to investigate placed the resident and others at continued risk for unsupervised exit, increasing the likelihood of serious harm. The facility's own investigation confirmed that staff did not respond appropriately to the alarm and did not account for the resident's whereabouts until notified by dietary staff.