Failure to Supervise Severely Cognitively Impaired Resident During Offsite Appointment
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment, resulting in an immediate jeopardy situation for multiple residents. Specifically, a resident with a BIMS score of 6, indicating severe cognitive impairment, was allowed to leave the facility unaccompanied for a medical appointment, despite facility policy requiring an escort for residents with a BIMS score lower than 13. The resident was not identified as at risk for elopement in the care plan, and the physician's order permitted the resident to leave unaccompanied when arranged by the facility. During the appointment, the resident was left unsupervised in the lobby, was not picked up as planned, and subsequently left the premises independently by calling a ride service and returning to his home. Review of facility records revealed that several other residents with severe cognitive impairment also had orders allowing them to leave the facility unaccompanied, contrary to the established escort protocol. Staff interviews confirmed that residents with severe cognitive impairment should not be permitted to leave unaccompanied, and that new residents should not have such orders until evaluated by a provider. Despite these protocols, the facility failed to ensure that care plans and physician orders were consistent with the residents' cognitive status and supervision needs. The incident was further compounded by the lack of elopement-related goals and interventions in the affected resident's care plan, and the absence of appropriate supervision during the transfer process. The resident was reported missing after the appointment, prompting a police search and notification of emergency services. The resident was eventually located at his home, having left the appointment site without facility staff knowledge or supervision. This failure to provide adequate supervision and to follow established protocols resulted in an immediate jeopardy situation for all residents with similar cognitive impairments.
Removal Plan
- Complete AMA discharge at residence.
- Call emergency services for hospital transfer for PICC removal.
- Notify Adult Protective Services.
- Notify Ombudsman.
- Review escort protocol.
- Educate staff on sending residents to appointments with escorts.
- Update elopement book.
- Conduct wellness check on resident.
- Conduct elopement drills every shift.
- Validate appointment returns.
- Develop protocol for offices to call building or driver for return and not put residents in the lobby.
- Review upcoming appointments and determine if escorts are needed in morning meeting.
- Update care plans.