Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report an elopement incident involving a resident to the State Agency as required. The resident, who had diagnoses including emphysema, malignant neoplasms, a history of TIA, and severely impaired cognition, was identified as being at risk for elopement due to exit-seeking behaviors and lack of awareness of safety needs. Interventions in place included a wanderguard device and regular safety checks, which were documented as being performed. Despite these measures, the resident was found missing, and staff initiated a search throughout the facility and outside. During the search, it was discovered that the resident was at a local hospital emergency department, as reported by the resident's daughter and the hospital administrator. The facility's Administrator, DON, and ADON were notified of the incident. However, a review of the State Agency's Certification and Licensure System revealed that no self-reported incident had been submitted regarding the elopement. In an interview, the Administrator stated she was unaware of the requirement to report elopements to the State Agency and did not know how to submit such a report. Facility policy required immediate reporting of all allegations of abuse, neglect, or exploitation to the Administrator and the Ohio Department of Health, but this protocol was not followed in this case.