F0610

D

Failure to Thoroughly Investigate Resident Elopement and Alleged Neglect

Syracuse, New York Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident elopement. The resident had multiple significant diagnoses, including diabetes, pneumonia, protein-calorie malnutrition, cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and history of suicidal behavior, noncompliance with medical treatment, anxiety disorder, and acute respiratory failure. On admission, the resident was assessed as alert and oriented, on 2L oxygen with diminished lung sounds, requiring supervision with meals and limited assistance with toileting, and having a history of falls. The comprehensive care plan documented that the resident had compromised respiratory status with oxygen therapy in place, was an elopement/wandering risk with a goal to remain safely in the facility, and had a history of suicide attempts.

On the date of the incident, the resident left the facility undetected and was last seen by staff at 2:00 PM, with their absence not discovered until 5:45 PM. The resident left the building without their required oxygen, did not receive ordered medications, and did not receive their evening meal. A 911 audio file later documented that the resident had walked or “snuck” out of the building on foot, and the caller, an RN starting the night shift, did not know when the resident left. In a later interview, the resident stated they told a staff member on the seventh floor they were leaving and the staff member responded dismissively. The resident reported packing their bags, using a wheelchair with oxygen to reach the lobby, then walking out the front door with their bags, leaving the oxygen behind because they could not carry it, and experiencing difficulty breathing when picked up by a stranger off the property. The resident stated no one attempted to stop them, ask where they were going, or request that they sign out.

The facility’s own policies required that all accidents/incidents, including potential abuse, neglect, and elopements, be reported and investigated, with the DON, ADON, Director of Investigations, or designee responsible. However, there was no documented evidence of a thorough investigation of this elopement. The facility initially reported there were no investigations for this resident, and when an investigation dated 03/04/2025 was later produced, it contained limited and incomplete information. Statements were obtained primarily from evening-shift staff who reported not seeing the resident for the entire shift and described overhead pages, a Code White, and searches after the resident was found missing. A recreation therapy director reported finding a wheelchair with an oxygen tank and name tag in an elevator and leaving it with security, but there was no documentation that information was obtained from reception, security, or day-shift staff about the elopement. The DON acknowledged that there were no statements from front desk staff, the nurse who called emergency services, the nurse who spoke with police, or the social worker who later met with the resident, and that the review of camera footage was not documented. The DON could not confidently state that all unknowns related to the incident were investigated. This lack of comprehensive documentation and follow-through on all relevant leads and witnesses constituted the failure to ensure that the allegation of neglect was thoroughly investigated.

Additionally, there were inconsistencies and gaps in the facility’s documentation regarding whether the resident left against medical advice (AMA). The DON stated the resident departed against medical advice and that emergency services were contacted for a wellness check for residents who left AMA, but there was no documented evidence that the resident left AMA on the date of elopement. A Nursing Discharge Against Medical Advice form was dated with the elopement date but signed and witnessed the following day, with the reason for leaving documented as not wanting to stay at the facility. The resident later reported being contacted by the facility and meeting a staff member at a friend’s house to sign papers that were not explained and that they did not know were AMA papers. These inconsistencies, combined with the absence of a complete investigative record, demonstrate that the facility did not conduct and document a thorough investigation into the circumstances of the resident’s elopement and the associated allegation of neglect.