The license of a South Florida Assisted Living Facility is in the process of being revoked by the Florida Agency for Health Care Administration. Revoking the facility’s license is in response to a 69-year-old resident who was reported as missing on September 18, 2021, and was found four days later deceased in an SUV in the facility’s parking lot.
The resident of the facility had repeatedly told staff that she was going to leave, and on September 18th at 8:30 a.m., the resident was unable to be located by the facility staff. The resident had not signed out of the facility. An employee stated that she asked the resident multiple times to stay at the facility, but the resident left, and the employee watched her walk out the front gate and into the parking lot. She said that she did not try to intervene. The employee told investigators that she then made a phone call to report what happened to the facility’s administrator. The resident was reported missing later that day by the facility. It wasn’t until four days later that she was found deceased in a SUV in the facility’s parking lot.
The facility violated state law when it failed to notify a licensed physician “when the resident exhibited signs of dementia or cognitive impairment or had a change of condition within 30 days.” The administrator stated that the resident needed to be watched and should not have been allowed to go outside alone due to a recent hospitalization for a change in condition. The resident’s physician and the case manager told the inspectors that the resident did not show any signs that she was at risk of leaving when they last saw her. The survey report stated that the facility “failed to provide appropriate personal supervision of care.”
The resident had been admitted to the assisted living facility two years earlier as a “limited mental health resident” and was diagnosed with a mental health condition. Florida state law requires that an assisted living facility with one or more mental health residents have a copy of a community living support plan and a cooperative agreement with a mental healthcare services provider for each resident. The community living support plan should be completed within 30 days of admission of the person to an assisted living facility.
The assisted living facility can appeal the health agency’s action to revoke their license and continue providing service until a Final Order is issued.
Issue:
Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident’s comprehensive assessment and plan of care. Not providing the necessary care and services to allow each resident the ability to maintain or achieve his or her highest practicable physical, mental, and psychosocial well-being may be viewed as substandard quality of care, which can result in a violation of 42 CFR 483.25 – Quality of Care. Quality of Care violations and lack of supervision can easily escalate to actual harm to a resident or residents, which could result in an immediate jeopardy citation for a facility.
Discussion Points:
- Review your policies and procedures for nursing services and other trained disciplines in providing quality of care for residents, as well as your protocols for prevention of and response to elopement. Update your policies as needed.
- Train appropriate staff on your policies and procedures for meeting residents’ needs for quality of care and adequate supervision. Ensure that staff are aware of where they can access the policies and procedures for easy reference. Document that the trainings occurred and file the signed documents in each employee’s education file.
- Periodically review medical record documentation and plans of care and observe all residents to ensure that quality of care and adequate supervision are provided, and that your policies and procedures are being followed.
