Failure to Investigate and Document Resident Elopement and AMA Discharge
Penalty
Summary
The facility failed to properly investigate and document an incident involving a resident who was not informed of, nor allowed to exercise, their right to leave the facility Against Medical Advice (AMA). The resident, who had a diagnosis of anoxic brain damage and was considered a high elopement risk, expressed a desire to leave, became agitated, and ultimately exited the facility by pushing open a fire exit door. Although the resident was under 1:1 supervision at the time, she managed to leave the premises before security could intervene. The staff involved reported the resident's behaviors and actions, but the required AMA documentation was not completed, and the incident was not treated as an elopement. The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not follow facility policy regarding incident investigation. They failed to collect and review staff witness statements and did not conduct a formal investigation into the circumstances of the resident's departure. The incident was handled solely as an AMA discharge, despite the resident leaving without authorization and without following proper discharge procedures. This lack of investigation and documentation was confirmed by the NHA and DON during interviews.