Failure to Supervise High-Risk Resident During Offsite Appointment
Penalty
Summary
A deficiency occurred when the facility failed to properly assess and supervise a resident with a known history of alcohol abuse, repeated falls, and high elopement risk during an out-of-state physician's appointment. The resident, who was cognitively intact but required supervision for some activities of daily living and had a documented history of returning from leave of absence (LOA) intoxicated, was allowed to attend the appointment without a staff escort or adequate supervision. Despite the resident's care plan and elopement risk assessments indicating the need for close monitoring, the facility relied on non-emergency ambulance transportation and did not ensure the resident's safe return. The resident did not return to the facility directly after the appointment as planned. Instead, he used public transportation to go sightseeing and returned to the facility later in the afternoon. This incident followed previous episodes where the resident failed to return as scheduled from LOAs, sometimes returning intoxicated and after being unaccounted for by both the facility and his friend who had signed him out. Documentation showed inconsistent and incomplete records regarding the resident's departures and returns, and staff interviews revealed a lack of clarity and adherence to policies regarding supervision and escort requirements for high-risk residents during offsite appointments. Staff members, including nurses and transportation personnel, expressed uncertainty about why the resident was unaccompanied and questioned his ability to make safe decisions, given his medical and behavioral history. The facility's policies required assessment and determination of the need for an escort for offsite appointments, but these procedures were not followed in this case. The lack of supervision and failure to implement appropriate interventions for a resident with known risks led to the deficiency cited by surveyors.