Failure to Thoroughly Investigate Resident Elopement Incident
Penalty
Summary
Facility staff failed to complete a thorough investigation of an alleged elopement involving Resident #1. The resident had a diagnosis of dementia and was assessed on the MDS as having severely impaired cognition. An incident form dated 2/11/2025 documented that staff witnessed the resident go out an exit door in the evening, proceed down a ramp, and be observed by staff who were spreading salt on the sidewalks. Staff in the parking lot were advised, and the resident was assisted back into the building and assessed by nursing with no injuries. The facility’s investigation, dated 2/19/2025, documented that the door alarm was sounding as the resident exited and that the resident was wearing a functional wander prevention device at the time. Review of the facility’s investigation revealed that it did not include documented witness statements or interviews from staff who witnessed the event or were working at the time of the incident. The investigation consisted only of an initial report and a summary of findings, without listing staff member names or their accounts. The Administrator confirmed that no written statements or interviews were obtained and that only a phone interview with the maintenance staff member was conducted shortly after the resident was brought back inside. Facility policies on Elopement/Missing Person and Accidents and Incidents – Investigating and Reporting required that the Report of Incident/Accident Form include names of witnesses and their accounts, but this information was not documented in the investigation of this elopement.
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