Failure to Thoroughly Investigate and Analyze Repeated Resident Elopements
Penalty
Summary
The facility failed to ensure a thorough investigation of multiple elopements involving resident #46. Facility-reported incidents documented that the resident left the premises without staff knowledge on several occasions over a span of weeks. The investigative files for these events lacked staff and resident interviews, did not identify root causes, and in one case contained no investigative information beyond copies of portions of the chart. The final report for the first elopement stated staff would be re-educated on elopement prevention procedures, but there was no documentation that this education occurred on or near the date of the incident, and the only education roster provided lacked a date, content description, and the name of the presenter. Staff interviews further showed that the investigations were not comprehensive. One staff member reported that the resident had a history of living in a homeless shelter and was potentially in a witness protection program, and that the resident was allowed to be outside smoking unattended because the facility did not have the manpower to supervise smokers. This staff member also stated that the resident’s activity care plan had been changed but could not recall what was needed to prevent further elopements. Another staff member stated she had never been interviewed about the elopements despite having ideas about how and why they occurred and how to prevent them. The staff member responsible for the investigation admitted she did not complete staff interviews and that a comprehensive review was not done, even though the facility later learned the resident had gone under a fence during one elopement rather than over it as initially believed. Across five additional elopements, the resident was identified as missing by community members rather than facility staff, and the investigation files remained incomplete and without timelines or precipitating factors.
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