Failure to Report Elopement Incident Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to report an incident of elopement involving a resident with severe cognitive impairment and a history of wandering. According to the facility's own algorithm, incidents of elopement require completion of an incident report, documentation in the resident's medical record, and submission of the investigation to the Department of Health and Human Services (DHHS). However, review of facility records showed no documentation or reporting of any elopement incidents in the past 12 months, despite progress notes indicating that the resident was found outside the building. Interviews with facility staff revealed that the incident was not investigated or reported to Adult Protective Services (APS) or DHHS. The Assistant Administrator stated that the event was not considered an elopement and no assessment was completed because there was no visible injury. The Director of Nursing was unaware of how long the resident was outside unattended and confirmed that the resident should not have been outside alone. The Administrator acknowledged that the incident was not reported to state agencies as required.