Failure to Report Elopement and Incomplete Abuse Investigations
Penalty
Summary
The facility failed to report an incident of resident elopement to the State Survey Agency (SSA) and did not conduct thorough investigations into multiple allegations of abuse. Specifically, a resident with cognitive impairment and a history of senile degeneration of the brain, anxiety, and diabetes mellitus type II eloped from the facility and was found in the parking lot heading toward a busy road. Although staff intervened and returned the resident to safety, the incident was not reported to the SSA as required. Additionally, the facility did not complete thorough investigations for several self-reported incidents (SRIs) involving allegations of verbal and physical abuse, as well as injuries of unknown origin. In each case, the investigation files only contained the SRI submitted to the SSA, with no evidence of staff or resident interviews, assessments of other potentially affected residents, or documentation of staff education. For one allegation of resident-to-resident physical abuse, there was no investigation documentation available at all. Interviews with facility staff, including the newly appointed Administrator, confirmed that the investigation files were incomplete and that no further documentation could be located. Review of the facility's own policy indicated that immediate and thorough investigations should occur for all allegations of abuse, neglect, or exploitation, including interviews and complete documentation, but these procedures were not followed in the cited cases.