Failure to Ensure Safe Return and Supervision of Visually Impaired Resident After Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with significant visual impairment and diabetes was not adequately supervised upon return from a medical appointment. The resident, who had a history of right eye exenteration for melanoma and a cataract in the left eye, required staff supervision for ambulation on both level and uneven surfaces, as documented in clinical and therapy assessments. Despite these needs, the resident was routinely transported to medical appointments by a contracted transportation company without evaluation for community mobility, and there were no procedures in place to ensure safe transfer of care back to facility staff upon return. On the day of the incident, the resident left the facility for a medical appointment with physician approval, which specified supervision by staff, family, or another authorized individual. However, after the appointment, the transportation driver dropped the resident off near the facility entrance but did not escort the resident into the building or sign them back into the care of nursing staff. Facility staff were unaware of the resident's whereabouts for an extended period and only realized the resident was missing after questioning and searching the building. The resident was later observed walking alone through the facility parking lot, having crossed a four-lane highway under construction to obtain food at a nearby restaurant. The resident had not received any food or a nutritious snack since leaving the facility that morning. Interviews with facility administration and nursing staff confirmed there were no policies or procedures to ensure residents were safely returned and signed back into the facility after outings with contracted transportation services.