Failure to Thoroughly Investigate and Document Multiple Resident Elopements
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document four elopement incidents involving one resident with exit-seeking behaviors. The resident left the building without staff knowledge on four separate occasions. During the first elopement, the resident exited when another family was entering the building and was outside for less than 10 minutes before staff were alerted by another resident’s family. Although staff witness statements from two CNAs were obtained, there was no documentation that the family who observed and reported the elopement was interviewed, and no additional investigation materials were present beyond what was in the facility reported intake. For the second elopement, the resident exited through a door that alarmed appropriately, and staff immediately returned the resident to the building after less than a minute outside. However, the report for this incident did not include any investigation actions such as obtaining witness statements from staff or family present at the time, nor evidence that other potential contributing factors, such as changes in mood or medications, were explored. During the third elopement, the resident was let out of the building by a resident from the attached assisted living center and was later found outside walking with another resident. The report did not specify which staff member found the resident, and no witness statements were gathered from staff or others present, including the CNA who saw the resident outside from her car and used her radio to notify staff, and another CNA who helped coax the resident back inside; both confirmed they were not interviewed and did not complete witness statements. During the fourth elopement, an LPN and a CNA responded to a front door alarm in the early morning hours, noted the resident’s room door open, and initiated a search. The CNA located the resident outside while the LPN was on the phone with emergency services, and the resident was assessed with no injuries and normal vital signs. Despite these events, the investigation records for this incident contained no witness statements from the involved staff. Interviews with the interim DON and administrator revealed there was no formal investigation form in use, the interim DON was unaware of existing witness statement forms, and investigations were being handled through progress notes and monitoring forms rather than a structured process. Facility policies on missing residents and abuse/neglect required detailed incident documentation and interviews of all involved staff, residents, and families, but the investigation team membership was not defined, and these policy expectations were not followed for the resident’s repeated elopements.
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