Failure to Protect Resident with Legal Guardian During Leave of Absence
Penalty
Summary
A resident with a history of hemiplegia, alcohol dependence, diabetes, and schizoaffective disorder, who had a legal guardian, was allowed to leave the facility on a leave of absence (LOA) with an unknown individual without the required consent from the legal guardian. The staff failed to verify the identity of the person signing the resident out, did not obtain a contact number, and did not confirm the destination or expected return time. The resident was signed out with only an illegible signature and insufficient information in the LOA logbook. The facility's policy required that residents with legal guardians could only leave with the guardian or those approved by the guardian, but this was not followed. After the resident left, multiple shifts of nursing staff failed to notice or report that the resident had not returned for approximately 30 hours. There was a lack of communication between shifts, and no progress notes were made regarding the resident's absence during this period. The absence was only discovered when a nurse on a later shift realized the resident was missing, at which point attempts were made to contact the family, guardian, and police. The legal guardian was not notified prior to the resident's departure, nor was she aware of the hospitalization that resulted from the incident. The resident was eventually found hospitalized for alcoholic ketosis and lactic acidosis after being exposed to high temperatures and consuming alcohol. The resident reported being left without a ride, walking in extreme heat, and ultimately requiring emergency medical attention. Interviews with staff revealed a lack of awareness of the facility's LOA policy, insufficient documentation, and failure to assess whether the resident could safely leave with the individual. The facility's investigation confirmed that staff did not follow required procedures for residents with legal guardians and did not ensure the resident's safety during the LOA.