Failure to Prevent and Assess Resident Exit in Cold Weather
Penalty
Summary
The facility failed to ensure a resident area was free from accident hazards and that adequate supervision was provided when one resident exited the building without staff knowledge in very cold weather. The resident, admitted with diagnoses including unspecified dementia, anxiety disorder, repeated falls, general weakness, balance deficit, and orthostatic hypotension, had a care plan addressing fall risk but no plan of care identifying elopement risk. A comprehensive MDS showed intact cognition and a BIMS score of 15, and the resident required partial assistance for bed mobility, transfers, and ambulation. On the day of the incident, nursing documentation only noted that the resident was observed outside by a COTA, with no further detail about the circumstances of the exit. Interviews revealed that direct care staff, including a CNA and the unit manager, were unaware that the resident had left the facility without staff or family. The resident reported going to the parking lot to see his car and acknowledged it was cold and that going out without a coat was unwise. The COTA stated she found the resident approximately 20 feet from the building and 50 feet from the door in the parking lot, wearing street clothes but no hat, coat, or gloves, and that he said he wanted fresh air. An LPN reported she had given the resident medications before he left to wait for his sister, later saw him being wheeled back by the COTA, and spoke briefly with him about signing out and dressing appropriately, but did not complete or document any assessment and could not verify which door he used or how long he was outside. The Administrator, DON, and QA nurse acknowledged that no investigation was completed and no further action was taken because of the resident’s intact cognition. The resident’s family, who reported prior notifications that he had tried to leave or was looking for the door, stated they were not informed that he had actually been outside without staff and without a coat.
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