Failure to Conduct Thorough Investigation After Resident Elopement
Penalty
Summary
The administrative staff failed to conduct a thorough investigation following the elopement of a resident identified as having exit-seeking behaviors. On the evening of the incident, the resident left the facility without staff knowledge, and the assigned LPN did not implement the facility's missing person protocol (Code Orange) as specified. The Administrator was not notified of the elopement until nearly two hours after the resident had left, and the resident's responsible party was not informed by the facility that the resident was missing. Instead, the resident contacted a family member directly, who then notified the facility of the resident's location. The resident was subsequently returned to the facility by local police and a staff member. The facility's investigation into the incident was incomplete, containing only a statement from the LPN involved and lacking interviews with other staff who were on duty or participated in the search for the resident. During interviews, the Administrator acknowledged that additional staff interviews should have been conducted and that a root cause analysis was necessary to determine where the process failed. The deficiency was identified through review of facility documents and staff interviews, which confirmed that the investigation did not meet the expected standards outlined in the job descriptions for the Administrator and Director of Nursing.