Failure to Timely Report Resident Elopement to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an elopement to the State Agency as required by its reporting policy and state licensure regulations. The facility’s undated policy titled “Reporting requirements” states that whoever first identifies or is notified of a potential self-report event must immediately notify the DON and Administrator after ensuring safety, and that the Administrator or DON will then proceed with required notifications and investigations. Record review of the facility’s reports to the State Agency showed that the elopement incident involving one resident was not reported within the required timeframes. The resident involved had a BIMS score of 5 on the MDS, indicating severe cognitive impairment, required total assistance with toileting, and extensive assistance with dressing and hygiene, but could walk 150 feet independently. Progress notes documented that the resident opened the back door of the facility and went out into the parking lot; the door alarm sounded and the resident was redirected back into the facility. A nursing assistant reported hearing a door alarm, checking the front door and finding no one exiting, then checking the back door, which was closed, and upon opening it observed the resident walking in the back parking lot. In an interview, the DON confirmed that the facility had not reported this elopement to the State Agency and acknowledged that it should have been reported.
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