Failure to Report Resident's Unexplained Absence to State Agency
Penalty
Summary
The facility failed to report to the State Survey Agency an incident involving a newly admitted resident who was no longer present in the facility and whose whereabouts were unknown to staff. According to facility policy, any suspected abuse, neglect, or unexplained absence must be reported immediately or within specified timeframes depending on the severity. The resident, who had diagnoses including muscle wasting, atrophy, and abdominal aortic aneurysm, was assessed as not having safe decision-making capabilities and required assistance for mobility. On the day of the incident, the resident was last seen outside with family, and later could not be located during routine rounds. Staff searched the facility and attempted to contact the resident and her representative without success, and the incident was reported internally to the DON. Despite these actions, there was no documentation that the resident was capable of making her own healthcare decisions, and no completed leave of absence form was found for her. The administrator and staff interviews revealed that the resident did not sign out as required, and there was confusion regarding her cognitive status and risk for elopement. The incident was not reported to the State Survey Agency as required by facility policy, and there was no evidence that external authorities were notified about the resident's unexplained absence.