Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to notify the Ohio Department of Health (ODH) of a resident elopement as required. Medical record review showed that Resident #09, who had multiple diagnoses including localization-related symptomatic epilepsy with simple partial seizures, COPD, chronic kidney disease, bipolar disorder, schizoaffective disorder, morbid obesity, and major depressive disorder, was admitted on an identified date and later transferred to the hospital. An MDS assessment indicated the resident was moderately cognitively impaired without documented mood concerns or behaviors. A nursing progress note documented that on a specific date the nurse was notified the resident was outside, 911 was called, and the nurse remained with the resident until emergency services arrived, stating that all parties were notified. Review of the Certification, Licensure, and Survey (CALS) system for the relevant time period revealed no evidence that the facility reported the resident’s elopement to ODH. During an interview, the Administrator confirmed that the resident had exited the building through his window and was found outside the facility, and acknowledged that ODH had not been notified. The Administrator stated that hospice had informed her they were required to report the incident to ODH, but she was not aware that she was also required to do so. Review of the facility’s Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy showed that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and all injuries of unknown source must be reported immediately to the Administrator or designee, and that if abuse was alleged or serious bodily injury identified, the Administrator/designee would notify ODH immediately but not later than two hours after the allegation or identification of serious bodily injury.
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