Failure to Review Resident Elopement in QAPI Committee
Penalty
Summary
The facility failed to ensure that a resident elopement incident was reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, as required by facility policy. A resident identified as having exit-seeking behaviors eloped from the facility without staff knowledge. 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 left, and the resident's responsible party was not informed by staff that the resident was missing. Instead, the resident contacted their family 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 assigned LPN and lacking interviews with other staff on duty or those involved in the search. Despite facility policies and QAPI guidelines requiring the committee to review reportable incidents and undesirable outcomes, the elopement was not brought before the QAPI committee for review. Both the acting DON and the Administrator confirmed in interviews that the incident had not been reviewed by the QAPI committee, contrary to expectations and established procedures.