Failure to Ensure Supervision During Offsite Medical Appointment Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and significant physical limitations was sent unaccompanied to an out-of-state medical appointment. The resident required assistance with all activities of daily living, had a history of neurological and psychiatric conditions, and was assessed as needing accompaniment for offsite appointments. Despite this, the facility arranged for transportation through an outside provider without confirming that an attendant would be present during the appointment. Documentation and interviews revealed that staff assumed an aide would be provided based on previous communications and prior appointments, but no direct confirmation was obtained for the specific appointment in question. On the day of the appointment, the resident was transported by medical transport arranged by the outside provider. Later that day, the facility was notified by the provider's office that the resident could not be located. The resident's wheelchair was found, and a search was initiated. The resident was eventually found over a day later at a nearby park, having eloped from the appointment location. The resident was subsequently hospitalized for five days with an acute kidney injury likely due to dehydration. Interviews with facility staff, including the unit secretary, unit manager, and DON, confirmed that there was no documented verification that an attendant would be present for the resident's appointment. The process for determining the need for accompaniment was handled verbally, and there was no written confirmation or follow-up to ensure the resident's safety during offsite appointments. The lack of confirmation and failure to provide adequate supervision directly led to the resident's elopement and subsequent hospitalization.