Failure to Timely Report Resident Elopement and Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident's elopement within the required 2-hour timeframe to the State Survey Agency and other appropriate authorities. The resident, an elderly female with multiple diagnoses including multiple sclerosis, type 2 diabetes mellitus, and unspecified dementia, had a documented risk for elopement and wandering behavior. Despite interventions in her care plan for close supervision and increased monitoring, the resident was able to leave the secure unit undetected. Staff first became aware of her absence over two hours after she left, and a facility-wide search was initiated later that morning. The incident report shows that the administrator notified the Complaint and Incident Intake Department of the elopement by email approximately 14 hours after the resident was discovered missing, well beyond the required 2-hour reporting window. Interviews revealed confusion among facility leadership regarding the correct reporting timeframe, with the administrator believing notification could wait until the resident was found safe, and the compliance nurse incorrectly stating the requirement was 24 hours. The resident was ultimately found by family members in a car one block from the facility and was hospitalized for heat stroke related to the elopement.