Failure to Report Resident Elopement to State Authorities
Penalty
Summary
The facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH) as required. A resident with vascular dementia and a moderately impaired cognitive status, as indicated by a BIMS score of 12, was observed by nursing staff preparing to go outside. The nurse allowed the resident to sit outside and documented that the physician was informed to obtain an out on pass order. However, the resident left the premises unaccompanied and was later found by police, who transported the resident to a precinct. While at the precinct, the resident experienced a syncopal episode and was transferred to the emergency room for evaluation. The facility's investigation concluded that the resident, who was alert and oriented, had verbalized a desire to go for a walk and sit outside, and an out on pass order was obtained and signed after the fact. However, a review of the medical record did not show a physician's order for the resident to go out on pass unescorted at the time of the incident. During interviews, facility leadership stated they did not report the elopement to NJDOH, believing it was unnecessary due to the out on pass order. The facility's policy requires reporting such incidents to state agencies within five working days, but this was not done.