Resident with Dementia Allowed to Exit Facility Unsupervised
Penalty
Summary
A deficiency occurred when a resident with severe memory impairment and a history of dementia was able to exit the facility unsupervised. The resident, who required assistance with personal care and had a low score on the Brief Interview for Mental Status (BIMS), was allowed to leave the building by a dietary aide. The aide let the resident out after he requested to check the weather, without notifying nursing staff or ensuring appropriate supervision. The resident was fully dressed and carrying blankets at the time. Shortly after, the facility was alerted by a local hospital that a man matching the resident's description was seen walking outside. A head count and search confirmed the resident was missing from the premises. The resident's roommate reported seeing him leave with a blanket, stating he was going home. Staff interviews and facility records confirmed that the dietary aide had used the code to let the resident out and did not inform other staff members. The resident was eventually located and returned to the facility by his wife and the local sheriff's office. Upon return, the resident was assessed and found to have no injuries or recollection of the incident. Facility policy required identification and supervision of residents at risk for unsafe wandering, but this was not followed in this instance, resulting in the resident's unsupervised exit.