Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to implement its abuse policy for one of two sampled residents when it did not report an elopement incident to the State Survey Agency (SSA) and did not investigate how the resident was able to leave the premises unsupervised. The resident, who had diagnoses including low back pain, osteomyelitis of the left shoulder, and a history of mental and behavioral disorders, was cognitively intact and required varying levels of assistance with daily activities. On the date of the incident, staff discovered the resident missing at approximately 6:30 a.m. and were unable to locate him despite searching the facility and contacting local hospitals. Attempts to reach the resident by cell phone were unsuccessful, and the police were notified to assist in the search. The resident returned to the facility at 1 p.m. the same day, at which point the police were informed that the missing person case was resolved. Documentation in the nursing progress notes confirmed the timeline of the resident's absence and the actions taken by staff, including notification of the physician and police. Interviews with staff, including LVNs, the registered nurse supervisor, the DON, and the administrator, revealed that the incident was not reported to the SSA as required by facility policy. Additionally, there was no investigation into how the resident was able to elope from the facility. The facility's policies on wandering, elopement, and reporting of alleged violations require immediate reporting and investigation of such incidents, but these procedures were not followed in this case.