Failure to Immediately Initiate Missing Resident Protocol
Penalty
Summary
The facility failed to immediately initiate its missing resident protocol, known as 'code pink,' when a resident with multiple complex medical conditions was discovered missing. The resident, who had moderately impaired cognition and required assistance with daily activities, was last seen in their room with a family member. After a blood sugar check revealed a high reading, a nurse received an order to administer insulin. When the nurse returned to the resident's room to give the medication, the resident and the family member were gone. Instead of immediately reporting the resident as missing and calling code pink, the nurse spent approximately 30 minutes searching the facility alone before notifying the charge nurse. Only then was code pink announced and a broader search initiated, including contacting the administrator, DON, and police. Security footage later showed the resident and family member leaving the facility during this time frame. The delay in following the facility's policy for missing residents resulted in the resident missing a prescribed dose of insulin for elevated blood sugar. Interviews with staff confirmed that the code pink should have been called as soon as the resident was found missing, and that the delay was not in accordance with facility policy. The facility's own policies require immediate action and notification when a resident is suspected missing.