Failure to Follow Missing Resident Policy After Unsupervised Departure
Penalty
Summary
The facility failed to follow its own policy for reporting and responding to a missing resident when a cognitively intact resident, with multiple medical diagnoses including COPD, malnutrition, anemia, alcohol dependence, mood disorder, and hypertension, left the facility without staff knowledge or supervision. The resident was allowed to go out on a community pass alone and was assessed as not at risk for elopement, but on the day of the incident, he left the facility at 4:45 AM with his belongings without notifying staff. The door alarm was triggered, and staff became aware of his absence only after another resident reported seeing him leave. Staff searched for the resident and notified the administrator, but did not contact the police as required by facility policy. Instead of immediately reporting the resident missing to law enforcement, staff and the administrator attempted to locate the resident by visiting his family member's home and other local places. The family member eventually encountered police and filed a missing person report several hours after the resident's departure. The resident was later found in another state, determined to be of sound mind, and not at risk to himself or others. The facility's documentation and interviews confirmed that the required steps of notifying police and filing a missing person report were not followed, despite the facility's written policy mandating these actions for any missing resident who did not sign out or notify staff.