Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report a resident elopement to the State Agency as required. A resident with diagnoses including chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced dementia and psychotic disorder, and moderate dementia with psychotic disturbance was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors. The resident's care plan included interventions such as distraction and structured activities, but no alarms or wander guards were in place. The resident was assessed as low risk for elopement, but an endangered missing adult alert was issued when the resident went missing. There were no nursing progress notes documenting the resident being missing or returning to the facility. During an interview, the Administrator confirmed that the facility did not notify the State Agency or open a self-reported incident through the Ohio Department of Health's Certification and Licensure System after being notified of the resident's absence. Facility policy required staff to investigate and report missing residents, but the policy was vague and did not specifically mention reporting elopements to the state agency. Another policy required notification of the Ohio Department of Health for all alleged violations involving abuse, neglect, or exploitation within 24 hours, but this was not followed in this case.