Victoria House The

Based on record review, interview, review of the police department call report, and facility policy review the facility failed to ensure Resident #43 did not leave the facility without staff knowledge and failed to investigate the incident of Resident #43 leaving the facility without staff knowledge. This affected one resident (#43) of three residents reviewed for elopement. The facility census was 61.

Findings include:

Review of the medical record for Resident #43 revealed an admission date of 03/24/23. Diagnoses included depression and dementia.

Review of the elopement risk dated 07/05/23 revealed he was alert and oriented to person, place, and time and had no history of wandering behaviors. He was a low risk for elopement.

Review of a progress note dated 07/04/23 at 1:42 P.M. revealed Resident #43's daughter was concerned her father was not acting like himself. The nurse talked with the resident and turned the air conditioning on in his room as it was noted to be very warm, and he reported breathing harder than normal. He was scheduled to see the physician or nurse practitioner the following day at the facility.

Review of the Police Department call report dated 07/05/23 revealed a man fitting in the description of Resident #43 was found walking on the street at 6:51 A.M. At 6:59 A.M. he was identified as Resident #43. He was escorted back to the facility by police at 7:04 A.M. Staff reported they did not know he had left the facility.

Review of a progress note dated 07/05/23 at 7:05 A.M. revealed Resident #43 left on an unsupervised leave of absence (LOA) without staff knowledge. He was assessed and no injuries were found, he was placed on 15-minute checks between 6:00 A.M. to 10:00 P.M. and hourly checks between 10:00 P.M. and 6:00 A.M.

Interview on 07/10/23 at 1:00 P.M. with Resident #43 revealed he was alert and oriented. He recalled going for a walk about a week ago and confirmed he did not let anyone at the facility know. He revealed he did not know he needed to tell staff where he was going.

Interview on 07/10/23 at 11:28 A.M. with Resident Care Coordinator (RCC) #200 confirmed Resident #43 went for a walk and did not tell anyone he was leaving. She confirmed the police brought him back to the facility around 7:00 A.M. She confirmed the facility's doors are locked from 10:00 P.M. until 6:00 A.M. so he could not have been out of the facility for more than one hour. She confirmed the facility did not put any preventative measures in place after the daughter brought concerns to her the day before.

Review of the medical record revealed no evidence an investigation was conducted to determine how Resident #43 left the facility without anyone knowing.

Interview on 07/10/23 at 1:30 P.M. with the Executive Director confirmed no investigation was completed regarding the incident involving Resident #43, and no staff education was provided to prevent a reoccurrence of a resident leaving the facility without staff knowledge. She confirmed the facility did not put any preventative measures in place after the daughter brought concerns to the nurse the day before.

Review of the undated facility policy titled Elopement revealed the facility would maintain a safe environment for all residents.

This violation represents non-compliance investigated under Complaint Number OH00144282.