Failure to Report Elopement and Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to report two significant incidents to the State Survey Agency (SSA) as required by policy and regulation. In the first incident, a resident with a Full Code status was found not breathing and without a pulse, but staff did not initiate CPR as ordered. Both the LPN and the Administrator confirmed that CPR was not started, and review of the facility's reporting system showed no evidence that a self-reported incident (SRI) was submitted regarding this failure to implement life-saving measures. The resident's medical history included COPD, dementia, prostate cancer, and congestive heart failure, and the care plan specifically directed staff to initiate CPR and call 911 in such situations. In the second incident, another resident, who was cognitively intact and had multiple diagnoses including angina, depression, and schizoaffective disorder, exited the facility without staff knowledge and went to a nearby store. The resident exhibited delusional behavior and required emergency services, though ultimately returned to the facility with staff assistance. Video surveillance confirmed the resident left the building unaccompanied. Despite management being made aware and the incident being documented, there was no evidence that an SRI was submitted to the SSA regarding this elopement. The Administrator confirmed she was not notified of the elopement and that no report was made.