Resident Left Facility Unnoticed, Missed Insulin Doses and Supervision
Penalty
Summary
A resident with diagnoses of diabetes and substance abuse, who was their own responsible party, left the facility without proper notification or supervision, resulting in a failure to administer scheduled insulin doses. Staff last observed the resident in their room between 1:00 P.M. and 2:00 P.M., but did not realize the resident was missing until approximately seven hours later. The resident did not sign out with the receptionist or notify nursing staff, and the required information on the Leave of Absence (LOA) form was incomplete, lacking an expected return time and staff initials. Multiple staff members, including CNAs, RNs, and the receptionist, failed to verify the resident's whereabouts during their shifts. The resident was not accounted for during routine rounds, and assumptions were made that the resident was in common areas such as the smoking area. The lack of communication and failure to follow the facility's Resident Outside Pass Policy and Elopement and Wandering Policy contributed to the delay in recognizing the resident's absence. As a result, the resident missed scheduled blood glucose monitoring and insulin administration, as documented by blank entries on the Medication Administration Record (MAR). Upon the resident's return, staff observed that the resident had developed new open areas on the thighs and a sore on the foot, which were not present prior to the absence. The resident was found in an unclean state, indicating a lack of care during the period away from the facility. Interviews with staff revealed gaps in following established protocols for resident supervision, sign-out procedures, and timely medication administration, all of which contributed to the deficiency.