Failure to Coordinate with Law Enforcement and Notify Family After Resident Does Not Return from Pass
Penalty
Summary
The facility failed to coordinate with law enforcement and provide necessary information regarding a resident who left on an independent community pass and did not return. Despite the resident having a history of not returning from passes and being reported missing, the facility was unresponsive to multiple attempts by law enforcement to obtain information. The administrator did not contact the resident's family members listed on the face sheet, and there was no documentation of family notification. The administrator also did not initially respond to emails or phone calls from law enforcement, and there was no physical copy of the police report maintained by the facility. The facility did not notify the state health department, as the incident was considered a discharge against medical advice rather than an elopement. The resident involved had diagnoses including schizophrenia, insomnia, auditory hallucinations, cocaine abuse, movement disorder, major depressive disorder, and suicidal ideations, but was assessed as having intact cognition. The DON stated that independent passes are based on cognitive status, not psychiatric diagnosis, and that family is only contacted if designated as POA. However, social service notes indicated that the family was involved in the resident's care. The lack of communication and coordination with both law enforcement and the resident's family contributed to the facility's inability to report the resident's whereabouts or status.