Failure to Timely Implement Missing Person Policy for Wandering Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement its Missing Person Policy for a resident with a history of wandering and an identified elopement risk. The resident, who had diagnoses including vascular dementia, hemiplegia, and insomnia, was noted to have memory deficits and was independent with ambulation using a walker. The care plan indicated the use of a wander guard placed in a tennis ball on the walker, as the resident would remove the device if placed on their body. On the date of the incident, the resident was last seen at 4:30 AM, and by 5:15 AM, staff realized the resident was missing. Staff initiated a search of the building's interior and exterior, and the DON was notified at 6:00 AM. Despite the facility's policy requiring police notification within ten minutes of discovering a missing resident, the police were not contacted until 6:03 AM, approximately 45 minutes after the resident was found to be missing. The resident was eventually located at 6:40 AM and was transferred to the hospital for evaluation, where injuries including a skin tear and contusions were identified. Interviews confirmed that staff did not follow the policy's timeline for police notification, and the DON acknowledged the delay in contacting authorities.