Failure to Supervise and Report Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and ensure timely reporting of an elopement for a resident with severe cognitive deficits. The resident, who had a history of non-traumatic intracerebral hemorrhage and a BIMS score indicating severe cognitive impairment, was able to leave the facility unsupervised. The resident reported walking up and down the street to go to a store, and was eventually returned to the facility by a staff member who happened to see him outside. Interviews with staff confirmed that the resident was not being supervised at the time of the incident, and that no staff were following him when he left the premises. Further review revealed that the incident was not reported to law enforcement, the ombudsman, or the California Department of Public Health (CDPH) as required by facility policy and state regulations. The Social Service Assistant stated that the incident was not reported because the resident did not disappear, while the Director of Nursing acknowledged that the resident did not have an out-of-facility pass and was vulnerable to injury during the episode. The facility's policy requires reporting of unusual occurrences affecting resident safety within 24 hours, but this was not followed in this case.