Failure to Timely Report Elopement and Potential Neglect Incident
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving potential neglect related to a resident elopement, as required by regulation and facility policy. A resident with dementia and moderately impaired cognition, confirmed by a BIMS score of 8/15, had documented wandering behaviors and was assessed as being at significant risk of getting to a potentially dangerous place. The resident’s care plan identified them as an elopement risk with a history of wandering and exit-seeking behaviors and impaired safety awareness, and included interventions such as one-on-one supervision, structured and meaningful activities, and use of a wander guard device on the left wrist with checks for placement every shift and function checks daily. On the date of the incident, the resident’s wander guard alarm activated when the resident exited the building, but staff did not respond to the alarm in a timely manner. The facility’s own elopement policy stated that alarms are not a replacement for necessary supervision and that staff are to be vigilant in responding to alarms promptly, and that adequate supervision will be provided to help prevent accidents or elopements. A CNA later reported hearing the alarm but stated the alarms are hard to hear and that she responded as soon as she could; by the time she responded, the resident had already eloped from the building and was found outside the front doors on the sidewalk, sitting in a wheelchair and stating they were getting some fresh air. The resident was brought back inside and had no injuries, and staff reported the incident to the DON. Despite the elopement and the resident’s known elopement risk, the DON reviewed the elopement policy on the day of the incident and initially determined the event was not reportable because the resident did not leave the property. The incident was not reported to the State Survey Agency within two hours, even though it involved potential neglect related to lack of supervision. The administrator later determined the incident was reportable due to lack of supervision and submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report the following day, outside the required timeframe. In addition, the misconduct incident report required within five business days of discovery was not successfully submitted within that timeframe, and the administrator did not use the available email system when experiencing difficulty with the electronic reporting system, resulting in further delay in required reporting.
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