Failure to Investigate Resident Incidents and Elopement
Penalty
Summary
The facility failed to initiate thorough investigations into incidents or accidents involving two residents, as required by its own Accident and Incident-Investigating and Reporting policy. For one resident with anxiety, diabetes mellitus, and bipolar disorder, clinical records showed that the resident was found in the basement near the kitchen after seeking out kitchen staff regarding her dinner menu. Despite this incident, there was no evidence of a comprehensive investigation being conducted. Another resident, with a history of seizures, hypertension, and alcohol dependence, was observed ambulating to the first floor, exiting the building through a side door, and being spotted by staff outside the facility. The facility administrator confirmed during an interview that no thorough elopement investigation was conducted for either resident, as required by facility policy and state regulations.