Failure to Report Allegation of Neglect After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect related to a cognitively impaired resident who was found outside the building. The resident had vascular dementia, diabetes mellitus, and a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment, but was documented as having clear speech. The resident’s care plan and physician’s orders identified him as an elopement risk and required a wander/elopement alarm (wanderguard) to be in place and checked regularly for placement and function. Treatment administration records showed all required checks as completed. A visitor reported that on an evening visit to return laundry, the front door was locked, no one was at the reception desk, and an alarm was sounding inside. The visitor stated they waited about 10 minutes at the door, then saw a resident come around the side of the building wearing pants and a short-sleeved shirt, without a coat, and appearing visibly cold, with a wanderguard on the right wrist. The visitor asked the resident his name, and he responded with his first name, which matched the resident later identified by the surveyor. The visitor reported calling the facility multiple times with no answer, then calling 911; the 911 operator reportedly called the facility twice before staff answered. A female staff member then came to the door, asked the resident how he got out, and took him back inside toward Unit 1. The visitor stated they called the facility the next day and spoke with the DON to ensure the incident of the resident being outside was reported, and the DON said they would investigate. During the survey, the ED and DON initially stated that no one had called them about the resident being found outside. When informed of the visitor’s account, the DON acknowledged receiving a call on a prior date but said the caller gave a similar-sounding name that did not match any resident, and that an investigation had been done but they could not determine whether any resident had been outside. The facility’s Abuse, Neglect, and Exploitation policy defined neglect to include failure to take precautionary measures to protect resident safety, failure to report observed or suspected abuse or neglect, and failure to adequately supervise a resident known to wander from the facility without staff knowledge, and required reporting all alleged violations of abuse or neglect to the administrator and regulatory bodies within specified time frames. The surveyor concluded the facility failed to report an allegation of neglect involving this resident in accordance with its policy and regulatory requirements.
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