Failure to Report Elopement Incident and Lack of Supervision
Penalty
Summary
A resident with a history of encephalopathy, generalized anxiety disorder, mild cognitive impairment, and alcohol use was identified as being at risk for elopement, as documented in their care plan and supported by multiple assessments indicating moderate cognitive impairment and wandering behaviors. The resident had an electronic wander bracelet in place and was subject to interventions such as a leave of absence (LOA) with escort and daily monitoring of the wander device. Despite these measures, the resident exited the facility without following the proper sign-out process, after another resident requested the door be opened by a CNA. The wander guard alarm was triggered but staff did not respond, and it was unclear who silenced the alarm. The resident was found outside the facility by law enforcement and returned unharmed. The incident was not documented in the facility's abuse/neglect log or incident and accident reports for the relevant period. Interviews with staff revealed that the CNA who opened the door did not see the resident leave and did not hear the alarm. Other staff members reported that the resident had exhibited exit-seeking behaviors earlier in the day, and this information had been communicated to nursing staff. The resident's care plan and assessments consistently identified elopement risk, and interventions were in place, but the facility failed to ensure adequate supervision and response to the alarm system. Despite the resident's known risk factors and the occurrence of an unauthorized exit, the facility did not report the incident as required. The Nursing Home Administrator and Director of Nursing stated that they did not consider the event reportable, as they believed the resident was alert, oriented, and not in harm's way. However, the facility's own policies define neglect as the failure to provide necessary services to avoid harm, and require reporting of such incidents. The lack of documentation and reporting of the elopement constituted a failure to comply with regulatory requirements for timely reporting of suspected neglect.