Failure to Ensure Safe and Documented Resident Discharge
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of a resident who left the facility. According to the report, a resident left the facility at an unknown time, and staff did not realize the resident was missing until several hours later. An Elopement Code was called when staff noticed the absence, but it was cleared based on the assumption that the resident had been discharged, as the resident had expressed a desire to go home and their belongings were missing. However, there was no documentation or evidence to confirm a safe discharge, and the facility was unable to determine the exact time or circumstances of the resident's departure. Interviews with the DON and Administrator revealed that both were uncertain about when the resident left and could not provide evidence of a proper discharge process, including the provision of paperwork, medications, or homecare services. The resident later confirmed that they left with a friend and did not receive any discharge materials or arrangements. The facility's management did not take appropriate action to ensure the resident's safety or to verify the resident's whereabouts in a timely manner.