Failure to Report Resident Elopement Incidents
Penalty
Summary
The facility failed to report two separate elopement incidents involving a resident on 04/28/25. According to the facility's policy, the Director of Nursing (DON) or designee is required to notify the Administrator and appropriate agencies, as well as the resident's legal representative, in the event of an elopement. However, documentation and interviews revealed that after the resident exited the building twice—once being found lying in the middle of a main road and once being found in the parking lot—these incidents were not reported to the required authorities. Progress notes and staff interviews confirmed that the resident, who was known to ambulate independently and had risk alerts for agitation and exit-seeking behavior, was able to leave the facility undetected on two occasions. Staff responded by searching for and returning the resident to the building, and the DON and unit manager were notified internally. The resident was later sent to the emergency room for evaluation after the second elopement, but there was no evidence that the incidents were reported externally as required by policy. Interviews with facility staff, including the DON, LPNs, and the unit manager, indicated confusion and miscommunication regarding the reporting process. The DON stated she believed the incident had been reported after consulting with the Administrator and a Nurse Consultant, who advised that the event did not need to be reported. However, no investigation or external notification was completed, and the current Administrator was unaware of the events, indicating a breakdown in the facility's reporting procedures.