Failure to Supervise Cognitively Impaired Resident Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with fluctuating cognitive impairments, resulting in the resident leaving the facility unsupervised. The resident, who had diagnoses including Parkinson's, diabetes, bipolar disorder, schizophrenia, and dementia, was noted to have episodes of forgetfulness, confusion, impaired vision, and a lack of safety awareness. Despite these conditions, the resident was allowed to sign himself out of the facility with no documentation of his destination, who he was with, expected return time, or what he was wearing. Staff were unaware of his whereabouts for several hours. Multiple staff interviews revealed that the resident was new to the facility, and several staff members did not know his cognitive status or medical history. The assigned LPN admitted to not completing or documenting the required initial clinical assessment and did not update the resident's record to reflect his confusion and lack of safety awareness. The agency nurse who facilitated the resident's sign-out did not verify whether the resident had a power of attorney, did not check his medical record for responsible party status, and did not inquire about his plans or ensure he had necessary medications. Other staff members were either not assigned to the resident or were preoccupied with other duties, resulting in a lack of supervision and monitoring on the resident's hall. The resident was later found by police several hours after leaving the facility, sitting confused and lethargic by a busy highway, with multiple abrasions, bruises, and signs of exposure to cold. He was transported to the emergency room, where he was found to be disoriented, unable to provide his name or location, and required medical treatment for his injuries and dehydration. The facility did not notify the resident's family or report the incident to the state, and there was confusion among staff regarding responsibility for the resident's safety once he had signed himself out.