Failure to Report Resident Elopement as a Facility-Reported Incident
Penalty
Summary
The facility failed to report an incident of potential neglect related to an elopement involving Resident 28 to the State Survey Agency. Resident 28, admitted in February 2025 with diagnoses including anxiety and a cognitive communication deficit affecting expressive and receptive language, was found on 3/6/25 at approximately 4:30 PM about a block away from the facility next to a busy street. An Elopement Investigation Report dated 3/7/25 documented that the root cause of the incident was the resident’s confusion and a non-functioning wander guard (electronic monitoring device). Despite this documented elopement event and investigation, there was no evidence that the incident was reported to the State Survey Agency. During interviews, the former Administrator (Staff 40) stated she could not remember if the elopement was reported and indicated she would not report an elopement because it was no longer listed on the Facility Reported Incident (FRI) form. The current Administrator (Staff 1) stated that, to his knowledge, no FRI was completed for the resident’s elopement, and the Regional RN (Staff 22) stated that if there was an alleged violation, it would be expected that an FRI be submitted for an elopement.
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