Failure to Report Alleged Elopement to State Authorities
Penalty
Summary
The facility failed to immediately report an alleged violation involving elopement to the State Survey Agency as required by regulation and its own elopement policy. The facility’s policy dated 7/14/2021 directed staff who discovered a resident missing to thoroughly search the building and premises and notify the administrator, DON, the resident’s legal representative, attending physician, and law enforcement agencies. Resident #5 had diagnoses including alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence. An Interdisciplinary Assessment dated 10/13/2025 documented the resident as an elopement risk, although the Minimum Data Set dated 10/18/2025 showed the resident was cognitively intact with a BIMS score of 14/15 and no documented wandering behavior. On 10/18/2025, an LPN documented that they were notified the resident was not in their room or the lobby, and they notified the DON, medical provider, and the resident’s Health Care Proxy, stating the resident had left against medical advice. Health Care Proxy #1 reported that the resident had left in the middle of the night and that they were not called by the facility until 9:00 AM, at which time the LPN asked if they knew the resident’s whereabouts because the resident could not be located. Health Care Proxy #1 stated they had an alert from the local hospital’s portal that the resident had been in the emergency department since around 8:00 AM and then informed the facility of the resident’s location, later observing the resident in the emergency department with all belongings. The DON stated in interview that the resident was alert and oriented and that the facility had no responsibility if the resident wanted to leave, and after reviewing camera footage from the morning of 10/18/2025, reported that the resident was seen in the lobby with all belongings at 6:42 AM and then leaving through the front door after a staff member returned from break. The DON stated this was not considered an elopement because the resident was alert and oriented and therefore it was not reported to the New York State Department of Health, resulting in the failure to report the alleged violation involving elopement as required.
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