Failure to Timely Report Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the appropriate authorities as required by regulation. Specifically, the facility did not report an incident in which a resident with severe cognitive impairment and multiple mental health diagnoses eloped from the facility. The resident, who was assessed as being at risk for wandering and required a wander guard bracelet, was found outside the facility on the street by a staff member. Upon return, the resident was noted to have a skin tear on his left arm, which was treated by nursing staff. Documentation in the resident's clinical notes and an accident/incident report confirmed the elopement and injury. However, a review of the Texas Unified Licensure Information Portal showed that no incident report regarding the elopement was submitted to the state agency. Interviews with current and former staff, including the DON and Administrator, revealed that the incident was not reported to the state, and there was uncertainty among staff about whether the event was reportable. The facility's own policies required immediate reporting of such incidents to regulatory authorities, but this protocol was not followed in this case. The failure to report the elopement and associated injury was identified through observation, interview, and record review. The deficiency was further substantiated by the lack of documentation in state reporting systems and by staff interviews indicating a lack of awareness or recall of the incident. The facility's in-service training records showed that staff had been trained on abuse prevention and timely reporting, yet the required reporting procedures were not implemented for this event.