Failure to Supervise and Timely Assess Resident for Wandering Risk
Penalty
Summary
The facility failed to provide adequate supervision and timely assessment to prevent a resident from leaving the premises without staff knowledge. A resident with diagnoses including Alzheimer's disease, schizoaffective disorder, and moderate cognitive impairment was last seen by staff and a visitor when going outside independently. The resident was not accounted for during lunch, and a search was initiated after staff realized the resident was missing. The resident was later found at a group home 1.2 miles away and returned to the facility without injury. There was no current physician order permitting the resident to sit outside independently, and staff were unaware of the resident's whereabouts for over an hour. Additionally, the facility did not complete a wander assessment in a timely manner. The last documented wander assessment for the resident was over 19 months prior, despite recent documentation of wandering behaviors by an APRN. Facility policy required supervision to prevent avoidable accidents, but staff failed to monitor the resident appropriately and did not reassess the resident's risk for wandering when new behaviors were identified.