Failure to Thoroughly Investigate Alleged Elopement and Neglect Incident
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of neglect involving a cognitively impaired resident with vascular dementia and diabetes mellitus who was care planned and ordered for elopement precautions, including a wander/elopement alarm (wanderguard) to the right wrist and routine checks of its placement and function. The resident’s MDS showed severe cognitive impairment but clear speech, and the care plan identified the resident as an elopement risk who wandered aimlessly. Physician orders and the treatment administration record documented that wanderguard placement and function checks were completed as ordered. A visitor reported arriving at the facility in the early evening to return laundry and finding the front door locked with no staff at the reception desk, while hearing an alarm sounding inside. After approximately 10 minutes at the door, the visitor observed a resident walking around the outside of the building from the right side, 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 the resident responded with his first name. The visitor stated they repeatedly called the facility with no answer, then called 911; the 911 operator reportedly called the facility twice before someone answered, after which a female staff member brought the resident back inside toward Unit 1. The visitor later called the DON the next day to ensure the incident was reported, and the DON stated they would investigate. When surveyors interviewed staff, multiple CNAs and an RN stated they did not recall the resident being outside on the reported date. The ED and DON initially stated no one had called them about the resident being outside; the DON later acknowledged receiving a call but believed the name given did not match any resident. The DON provided witness statements and a body/skin inspection form dated around the time of the alleged incident, but the unit manager (LPN) reported obtaining the statements on a later date and instructed staff to date them for the day of the incident, resulting in discrepancies between the actual date statements were taken and the dates written on them. Some staff named on the witness list either denied giving a statement or reported giving one on a different date than documented. These inconsistencies, along with the lack of clear documentation of the alleged elopement and the facility’s own abuse/neglect policy requiring immediate, documented investigation with timely, signed, and dated statements, demonstrated that the facility did not complete a thorough investigation of the neglect allegation.
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