Resident Left Unsupervised During Outpatient Appointment
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes mellitus, and a history of stroke was not adequately supervised during an outpatient dental appointment. The resident was identified as severely cognitively impaired and had demonstrated behaviors such as frustration and anger, with interventions in place to allow adequate response time and anticipate needs. Despite an exit-seeking risk assessment indicating no known risk factors for exit-seeking, the resident was disoriented. During the dental appointment, the resident was accompanied by a nursing assistant (NA) who, after the appointment, waited outside the clinic with the resident for transportation. While waiting, the resident moved around the area, including using the bathroom twice and sitting or standing near the NA. At one point, the NA was distracted by a phone call regarding transportation and lost visual contact with the resident for approximately five minutes. Upon realizing the resident was missing, the NA searched the clinic and surrounding area before notifying facility staff. The incident was escalated to the facility administration, and local authorities were contacted to assist in the search. The resident was eventually found unharmed at a gas station two miles from the clinic and was transported to the emergency department for evaluation. The facility's policy required staff to maintain close proximity and line-of-sight supervision of residents during appointments, which was not followed in this instance, resulting in the resident being left unsupervised.