F0609

D

Failure to Timely Report Resident Elopement as Alleged Neglect

Appleton, Minnesota Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report an incident of neglect, specifically an elopement, to the State Agency (SA) within the required two-hour timeframe. On 1/11/26, a resident identified as R1 self-propelled in a wheelchair toward the dining room door leading outside. Facility incident documentation indicated that R1 exited the building through the south exit door by the dining room; the wander guard alarm did not activate, and R1 was found approximately 15 feet outside the door. R1 was wearing two sweaters, shoes, and carrying a bag. Staff spent time attempting to calm and redirect R1 while outside, and R1 eventually agreed to return inside on the condition of being allowed to speak with the doctor. R1 was assisted back into the facility safely.

Camera footage reviewed on 1/22/26 showed that at 9:17 a.m. on 1/11/26, R1 was in the wheelchair self-propelling toward and then through the dining room door to the outside, with two other residents present in the dining room and one staff member briefly entering to escort another resident out. Staff were observed joining R1 outside at 9:19 a.m., and R1 returned inside with staff at 9:29 a.m. The facility reported the incident to the SA at 2:40 p.m. on 1/11/26, which exceeded the two-hour reporting requirement. During interview, the DON stated she did not report within two hours because there was no harm to R1 and believed that when there was no harm, the reporting timeframe was 24 hours. The DON acknowledged that the facility policy and regulations, which require reporting alleged violations of abuse, neglect, exploitation, or mistreatment immediately but not later than two hours if involving abuse or serious bodily injury, and not later than 24 hours otherwise, were not followed.