Failure to Supervise Cognitively Impaired Resident Leading to Unattended Departures
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure a safe environment for a resident with significant cognitive impairment and poor safety awareness. The resident, who had a history of stroke, heart disease, encephalopathy, and demonstrated moderate to severe cognitive decline, was not initially identified as an elopement risk upon admission. Despite multiple documented instances of confusion, disorientation, and wandering behavior, the resident's care plan was not updated to reflect their cognitive decline or risk for elopement. The resident left the facility unattended on more than one occasion, including one instance where they signed themselves out and did not return as expected, prompting staff to contact the family and law enforcement. Another time, the resident left with another resident without signing out and returned after midnight. There were also episodes where the resident returned to the facility exhibiting signs of intoxication, and documentation was lacking regarding their whereabouts and the duration of their absence. Staff and family interviews confirmed the resident's ongoing confusion, lack of safety awareness, and inability to make safe decisions independently. Despite therapy and nursing notes indicating the resident's cognitive impairment and safety concerns, there was no timely update to the elopement risk assessment or care plan. The resident was not consistently identified as an elopement risk until months after the initial incidents, and interventions such as wander guard devices were not effectively implemented or documented. The lack of updated assessments and care planning contributed to the resident's repeated unsupervised departures from the facility.