Failure to Timely Report Resident Elopement Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulation. Specifically, the facility did not report two separate elopement incidents involving a resident with significant cognitive impairment and multiple medical conditions, including end stage renal disease, dementia, and altered mental status. The first incident occurred when the resident was found outside the facility attempting to cross the street, and the second incident involved the resident being found across the street at an apartment complex. In both cases, there was no evidence that the incidents were reported to the State Survey Agency (SSA) as required. The resident in question had a documented history of confusion, memory loss, and impaired decision-making, and was assessed as being at risk for elopement. Despite this, there were no elopement assessments completed prior to the second incident, and the care plan interventions for elopement risk were not implemented until after the resident was found outside the facility. Staff interviews revealed inconsistencies in the recognition and reporting of the elopement events, with some staff unaware of previous incidents and others unsure of the reporting requirements. There were also no incident reports or witness statements completed for either elopement event. Facility policy required immediate reporting of suspected abuse, neglect, or elopement to the appropriate authorities, but review of records and staff interviews confirmed that these procedures were not followed. The events were not documented in the facility's reporting system, and the required notifications to the SSA were not made. The lack of timely reporting and investigation of these incidents constituted a failure to comply with regulatory requirements for the protection of residents.