Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to conduct a thorough investigation following an elopement incident involving a resident with dementia, Parkinson's disease, anxiety, and high blood pressure. The resident was admitted to the facility on 3/28/2025 and eloped from the dementia unit on 12/9/2025. Review of the clinical record showed no documentation regarding the elopement on the day it occurred, and there was no evidence that an investigation was initiated or completed. Staff interviews and incident documentation were lacking, with no staff interviews or handwritten statements present in the clinical record. Video footage confirmed the resident was outside the facility and was later returned by staff, but the staff involved were not asked to complete incident reports. During interviews, a nursing assistant described the sequence of events, including responding to door alarms, searching for the resident, and ultimately assisting in returning the resident to the unit. Despite these actions, the facility administrator confirmed that no investigation was conducted into the elopement. The facility's policy required all accidents or incidents to be investigated and reported to the administrator, but this was not followed in this case, resulting in noncompliance with state regulations regarding management, resident rights, and nursing services.