Resident with Dementia Left Unescorted at Medical Appointment
Penalty
Summary
A resident with diagnoses including hypertension, epilepsy, and unspecified dementia was admitted to the facility and assessed as cognitively intact but requiring substantial to maximal assistance with walking and being dependent for transfers. The resident had an outside medical appointment, and according to family interview, was found alone at the appointment site with their wheelchair and medical documents, without a facility escort present. The family member expressed concern for the resident's safety due to the dementia diagnosis. Facility staff interviews revealed that the protocol is to send an escort with residents, especially those with cognitive impairment or dementia, unless family is present to assume responsibility. Documentation and staff statements indicated that the expectation was for an escort to remain with the resident until the family arrived. However, the escort left the resident at the appointment before the family arrived, contrary to facility policy and procedure, which requires staff to accompany residents with cognitive impairment when family is not available. This resulted in the resident being left unsupervised at the appointment site.