Failure to Investigate and Report Resident Elopement Incidents
Penalty
Summary
The facility failed to investigate and report possible incidents of abuse or neglect for one resident, as required by both facility policy and regulatory standards. Specifically, a resident with diagnoses including Parkinson's Disease, a history of traumatic brain injury, and schizo-affective disorder exited the facility without staff knowledge or their assistive device on two separate occasions. On one occasion, the resident was found by police sitting in the road outside the facility without having signed out or notified staff. Documentation showed that the resident was cognitively intact and had expressed a strong preference for going outside, but care plans required supervision and specific interventions for mobility and safety. Despite these incidents meeting the facility's definition of elopement, no incident report or investigation was completed for the first occurrence, and the required notifications to the administrator, Adult Protective Services, and the state regulatory agency were not made for either event. The Director of Nursing confirmed that these incidents constituted elopement and acknowledged that facility policy was not followed, as neither an immediate investigation nor timely reporting occurred as mandated.