Failure to Report Elopement and Fall With Major Injury to State Agency
Penalty
Summary
The facility failed to timely report to the State Survey Agency an elopement and a fall with major injury involving two residents, as required by its Abuse, Neglect, and Exploitation policy. The policy required all allegations of abuse, neglect, exploitation, and injuries of unknown source to be reported within 2 hours for serious bodily injury and within 24 hours if no injury, with investigation results submitted within 5 working days. One resident, with a history of traumatic brain injury, mood disorder, history of falling, inattention, disorganized thinking, depression, verbal behaviors that interfered with care and put others at risk, and documented wandering behaviors, left the facility twice on the same day without signing out or notifying staff. Progress notes showed that the resident’s care plan included preferences for walking outside and described the resident as very impulsive and not easily redirectable, but did not include interventions addressing wandering behaviors. On the second elopement, staff did not know where the resident was going, the resident’s wheelchair was later found near the drive-up area, and the resident ultimately returned with abrasions, complaints of shoulder pain, and required hospital evaluation for hypothermia and injuries from a fall. The Administrator confirmed this elopement incident was not reported to the State Agency. A second resident experienced a ground-level fall resulting in a right facial laceration that required transport to the hospital. The hospital discharge summary documented a right upper eyelid laceration with sutures, indicating a significant injury. Interview with a clinical consultant confirmed that this fall with significant injury was not reported to the State Agency, despite the facility’s policy requiring reporting of such events. These two unreported incidents, an elopement with injury and a fall with major injury, occurred among a sample of four residents in a facility with a census of 62 and constituted the basis for the cited deficiency under the licensure requirement to timely report suspected abuse, neglect, or theft and the results of investigations to proper authorities.
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