Resident Left Unsupervised Outside Overnight Due to Inadequate Rounding and Supervision
Penalty
Summary
A cognitively impaired resident with diagnoses of schizophrenia and psychotic disorder with hallucinations was left outside alone, unsupervised, and after hours in the secured unit's courtyard. The resident had a moderate cognitive impairment, required supervision or touch assistance with activities of daily living, and was identified as an elopement risk with a care plan intervention specifying supervision in the courtyard. On the evening of the incident, the resident requested to sit outside after supper. Staff opened the courtyard door, and residents went outside. Later, staff assumed all residents had returned inside and closed the door without verifying the whereabouts of the cognitively impaired resident. Throughout the night, staff failed to account for the resident's presence. Certified Nursing Assistants (CNAs) and nursing staff assumed the resident was in the bathroom when not seen in the room and did not perform visual checks or rounds as required. Rounds that were supposed to occur every two hours were not consistently performed, and staff did not check the resident's room or other areas to confirm the resident's location. The resident remained outside overnight in cold temperatures, knocking on the door and attempting to stay warm. The resident was discovered missing during morning rounds, and the Director of Nursing (DON) located the resident outside in the courtyard. The resident was brought inside, and a body audit revealed no negative findings. The incident was determined to be a failure to protect the resident from neglect, as the facility did not ensure adequate supervision and failed to follow care plan interventions and rounding protocols, resulting in the resident being left outside unsupervised for an extended period.