Would failure by staff to follow-up on an absent resident due to believing he was with his family, but had not signed-out, support a claim of substandard quality of care and provide the potential for submitting a fraudulent claim in violation of the False Claims Act? [F689 Free of Accident Hazards/Supervision/Devices and F600 Free from Abuse and Neglect]
Compliance Perspective – Absent Resident
Policies/Procedures: The Compliance and Ethics Officer, DON and Administrator will review policies and procedures covering requirements for staff to investigate concerns regarding suspicion of a missing resident. Training: Staff must be trained regarding protocols for the residents to sign-in and sign-out of the facility, and for following-up and verifying the location of any resident who is missing unexpectedly. Staff will also be instructed on the necessity of communicating with officials who are involved in any investigation. Training will also include protocols to follow when a secured door lock and alarm are broken. Maintenance personnel will be trained to conduct daily inspections of the alarm security system and the locks (electronic and manual) to ensure all are functioning. Audit: An audit will be conducted to inspect the facility’s exits for properly functioning locked doors and alarms, and drills will be conducted to evaluate the facility’s elopement protocol and staff response to the elopement or unexpected absence of a resident. The results of the audit and drills will be summarized and submitted to the QAPI/QAA Committee for review and recommendations and to the Compliance and Ethics Committee.
A 45-year-old resident in a Kentucky nursing and rehabilitation center using a motorized wheelchair crashed down a set of stairs. No one looked for him for many hours. He was found deceased at the bottom of the stairwell over nine hours later. The 166-pound chair had landed on top of his chest causing him to suffocate. He also sustained a head injury.
Staff were not concerned about his absence because they believed the resident had left on an unscheduled family outing and forgot to sign out. The exit door to the stairwell where the incident occurred was supposed to be secured with a lock and an alarm; however, both the door’s lock and the alarm were broken.
The resident is believed to have disappeared shortly after 11:25 that morning. An aide noticed him around that time sitting at the end of the hall by a window where he often sat. The aide delivering his lunch questioned her supervisor about his disappearance because his TV was on and his bag with his medications was in its usual spot. The supervisor assured the aide that he must be out with his family. Around 8:15 p.m., the evening aide became concerned when she found the resident’s cell phone on his bed, as he rarely went far without it. The aide followed-up with the supervisor and asked if the resident’s family had been contacted. The family was called, and the resident’s parents rushed to the center to look for their son along with the police and fire department.
The day supervisor who insisted that the resident was with his family refused to speak with the police or state inspectors. Her license was suspended as a result.
The nursing home was fined $73,710 by the state of Kentucky and a wrongful death lawsuit was filed by the resident’s parents who settled for an undisclosed amount.
