Failure to Investigate and Report Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation and proper reporting following an elopement incident involving a resident with dementia and moderately impaired cognition. The resident, who had diagnoses including high blood pressure, dementia, and insomnia, was found outside in the parking lot near a fire hydrant after exiting through an emergency door that was not locked. The event was discovered by another resident, who alerted staff after noticing the door was open and the resident was outside. Staff interviews confirmed that the door was used for deliveries and was not secured at the time, allowing the resident to leave the building unsupervised. Review of the clinical record revealed that there was no documentation of the elopement event, nor was there evidence of required notifications to the resident's family or physician. Additionally, the facility did not initiate or complete an investigation into the incident or the possibility of neglect, as required by facility policy. The Director of Nursing confirmed that no investigation was conducted, and the event was not reported to the appropriate agencies, constituting a failure to respond appropriately to an alleged violation.