City-Operated Residential Care Center allows resident with diminished capability to check herself out, and an associated Hospital on the same campus determines its protocol for searching for missing persons is inadequate.
Compliance Perspective – Deteriorating Cognitive Abilities:
The Compliance Officer should review the facility’s wandering and elopement policies and procedures with the DON, the Administrator and the Compliance Committee. The facility’s elopement risk assessment protocol should be evaluated to ensure that a resident’s deteriorating cognitive abilities are recognized, reported and appropriate changes and interventions are put in place when needed to prevent excessive wandering and elopement. Staff must be trained on how to observe and report significant changes in the cognitive ability of a resident and to consider how these changes might affect the resident’s need for additional care and supervision. Staff will also be trained on the process of executing a thorough search protocol including any nearby buildings that a resident might access. An audit will be conducted on a quarterly basis to evaluate the elopement risk assessments of the facility’s residents and to reveal any assessment deficiencies that may need to be addressed. The facility will schedule periodic drills to evaluate the facility’s ability to identify and locate a missing resident. Findings from the summarized audits will be reported to the QAPI Committee.
The California Department of Social Services (CDSS) recently cited a residential care facility for its failure to “recognize and report the deteriorating cognitive abilities” of a 75-year-old woman who was able to check herself out of the facility at 9 a.m. on May 19. The facility reported the woman as missing when she did not return by 4 p.m. that afternoon. The CDSS’ citation further alleges failure by the facility for allowing the woman to leave “the facility without appropriate care and supervision.”
The Community Care Licensing Division of the CDSS has ordered the facility to develop a plan to “prevent a repeated incident,” or it will be fined.
The woman was found dead on May 30, 11 days after she went missing, in the stairwell of a nearby hospital operated by the same public health department as the residential care facility where the woman lived.
The hospital acknowledged in a news conference the day after the woman was found that there were “gaps in their protocol that thwarted attempts to find her.”
Because the woman was not a medical patient in the hospital, the Sheriff’s deputies did not thoroughly search the hospital’s buildings even though it was located on the same campus and was just across the street from the care facility.
Ironically, another woman was found dead in one of the hospital’s stairwells 17 days after she went “missing from her hospital bed in September 2013. That woman’s family sued the City and settled for almost $13 million.
The family of the most recent woman’s elopement has hired the attorney who sued the City on behalf of the other missing woman.
