Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation to the State Survey Agency within 5 working days of an incident involving a resident. The incident involved a female resident with diagnoses including unspecified dementia, senile degeneration of the brain, anxiety disorder, major depressive disorder, and muscle weakness. On the day of the incident, the resident was found agitated and pounding on the secure unit door. Staff later discovered the air conditioning unit on the floor and the window open in her room. After a search, the resident was located in the secure unit courtyard within 30 minutes, with no injuries noted but continued agitation. She was subsequently discharged to a behavioral health hospital. The Administrator did not submit the required 5-day investigatory findings to the State Survey Agency, as she determined the event was not an elopement and believed reporting was unnecessary. The facility's policy requires comprehensive investigations and written reports to be sent to the appropriate authorities within five working days. Interviews with staff confirmed that the Administrator was responsible for the report and that the 5-day report was not submitted until after the surveyor's inquiry.