Resident Left Facility Property Unsupervised Despite Supervision Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses of paranoid personality disorder, bipolar disorder, and schizophrenia, and with moderately impaired cognition, was not provided adequate supervision to prevent leaving the facility property unsupervised. The resident had a history of confusion and exit-seeking behavior, which was documented in nurse's notes. Physician orders were in place for a Wanderguard device and for the resident to have supervised leave of absence (LOA), including for smoking. Despite these orders, the resident was allowed to go outside to smoke and was last seen by staff in the back parking lot area. Staff later realized the resident had not returned, prompting a search of the facility and surrounding area. The resident was subsequently found by local police walking in the street and became combative when approached, resulting in transport to the emergency room. Interviews with staff confirmed that the resident had an order for supervised LOA but left the property unsupervised. The facility census at the time was 70, and this incident affected one of four residents reviewed for LOA. The deficiency was substantiated through record review and staff interviews, confirming that the required supervision was not provided as ordered.