Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to investigate an incident of elopement involving a resident who was identified as an elopement risk and had a care plan in place with specific interventions, including the use of a WanderGuard device and regular monitoring. The resident, who had diagnoses including schizoaffective disorder, depression, and anxiety, was cognitively intact according to the most recent MDS assessment. On the date of the incident, the resident exited the building without staff knowledge after a visitor entered the facility, and went to a nearby store. The resident exhibited delusional behavior, refused to return, and emergency services were contacted but later canceled. The resident eventually returned to the facility with staff assistance. Despite the incident, the facility did not initiate an immediate investigation as required by its own policy on abuse, neglect, and exploitation. The DON was not aware of the unsupervised elopement until several days after the event, and an investigation was not started until that time. This lapse in timely response and investigation of the elopement constituted the deficiency cited by surveyors.