Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to conduct an investigation and report an allegation of potential neglect related to a resident elopement to the State Survey Agency. A resident with diagnoses including senile degeneration of the brain, chronic kidney disease, hypertension, diabetes, and heart failure, and who had impaired cognition, was found outside the facility by staff after being seen at a nearby pizza restaurant. The resident, who was independent in ambulation, had asked staff to remove her oxygen to go outside to smoke and was last seen near the facility earlier in the day. She was later located about a mile away, appeared confused, and stated she was trying to find her son's house and got lost. Staff interviews confirmed that the resident had not signed herself out and that facility staff were unaware she was outside until notified by an off-duty CNA who saw her in the community. Review of self-reported incidents and interviews with facility leadership revealed that no investigation was initiated and the incident was not reported to the State Survey Agency. The facility did not provide documentation of an investigation into the elopement, and the Regional Leader confirmed that a formal investigation was not commenced because it was believed the resident had taken a temporary leave of absence, despite evidence to the contrary. This deficiency was identified during a complaint investigation and affected one of three residents reviewed for elopements.