Failure to Timely Report Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report to the appropriate authorities when a resident with dementia and moderate to severe cognitive impairment was found to have eloped from the facility. The resident, who had a history of wandering and cognitive deficits, left the facility unsupervised and was later found walking near a restaurant by a staff member who was off duty. The incident was not reported to the State Survey Agency as required by regulations. The resident involved had diagnoses including dementia, mood disorder, anxiety, and bilateral hearing loss, and had a fluctuating BIMS score indicating moderate to severe cognitive impairment. Prior to the incident, the resident was not assessed as being at risk for elopement, despite a history of wandering at home. On the day of the incident, the resident was last seen by staff approximately 30 minutes before being observed outside the facility. Staff initiated a search and located the resident about an hour later, walking back toward the facility. Interviews and documentation revealed that the resident was confused, had poor judgment, and was not safe to be outside alone, especially given the proximity to a busy street and freeway. Despite the clear risk and the requirement to report such incidents, the facility did not submit a self-report to the appropriate authorities. Interviews with staff and administration indicated confusion and disagreement about the resident's cognitive status and whether the incident met the criteria for reporting. Some staff believed the resident was able to make his own decisions, while others recognized the severity of his impairment and the danger posed by his elopement. The lack of timely reporting was confirmed by a review of the Texas Unified Licensure Information Portal, which showed no incident report for the event.