Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report an incident of resident elopement to the state agency as required. A resident with diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia, who had a documented history of elopement and was identified as an elopement risk, left the facility without staff knowledge. The resident was supposed to be monitored with a wander guard device and redirected from exit areas, according to the care plan. Despite these interventions, the resident exited the facility, traveled to a nearby gas station, and entered a vehicle with a man known to the station manager. The manager, upon realizing the resident was from the facility, arranged for the resident to be returned. The administrator confirmed during an interview that a Self-Reported Incident (SRI) was not filed because she did not believe neglect had occurred, even though the resident was cognitively impaired and had left the facility unsupervised. Facility policy required reporting of such incidents within federally mandated timeframes, but this was not followed. The deficiency was identified during a complaint investigation and was based on medical record review, staff interview, and policy review.