Resident Unaccounted for Due to Inadequate Supervision and Communication Failures
Penalty
Summary
A deficiency occurred when a resident left the facility and was unaccounted for approximately 18 hours before management was alerted. The resident, who had a history of cerebral infection sequelae, left kidney injury, and right-sided hemiplegia and hemiparesis, was cognitively intact as indicated by a BIMS score of 15. The resident did not sign out or inform staff of his departure, and his absence went unnoticed by multiple shifts, including agency CNAs and nurses who were unfamiliar with the resident. The resident's television was left on and his dinner untouched, but these signs were not acted upon in a timely manner. Communication breakdowns occurred during shift changes, with staff assuming the resident was with family or that his absence was normal. Documentation in the medical record indicated the resident was not present, but this information was not escalated promptly. The night shift nurse was later found to have falsified documentation, indicating checks on the resident that did not occur. Agency staff, unfamiliar with the residents, contributed to the lack of awareness regarding the resident's whereabouts. The facility's procedures required residents to sign out in a Leave of Absence (LOA) book when leaving, but this protocol was not followed or enforced in this instance. The resident was eventually located after a pharmacy contacted the facility, and he was returned without injury. The incident revealed lapses in supervision, communication, and adherence to established protocols for monitoring resident whereabouts, particularly when agency staff were involved.