Saturday, November 21, 2015

Missing Resident or Out Walking

ICF/IID programs in Texas have dealt with the question of when to report a missing resident for years.  I was recently visiting with a program when a staff person reported, "This person is missing!  We think they ran off."  A management staff sitting nearby quickly pointed out, "No, they are not missing, they are out for a walk!"  While it was a serious moment, the comic relief provided is a view that many facilities have to deal with daily.  We live in a world where residents are encouraged to exercise their rights and one of the many rights they often exercise is the right to move freely on and off the facility site.  The question the facility has to face, is when does that right become a reportable incident. 

The Texas Administrative code offers some insight into this issue (Texas Code).  In this code we read that "a resident whose location has been unknown by the facility for more than eight hours or less than eight hours if there are circumstances that place the resident's health or safety at risk."  This standard would appear to be clear, but sadly it is not.  It leaves itself wide open for interpretation.   The first half is fairly clear - if the resident has been missing from the facility for more than eight hours.  That's easy enough in that you check the last known time the resident was in the facility against the current time.  If it is less than eight hours, the resident is not missing - they are simply out for a walk.  If it is over eight hours, then they are considered missing. 

The second part of the code presents issues that are open for interpretation.  In the second part, we suddenly find it stating "or less than eight hours if there are circumstances that place the resident's health or safety at risk."  Who decides what those circumstances are?  If the resident has a guardian, does the guardian determine them?  If there is no guardian, does the IDTeam determine them?  Does the QIDP determine them?  Does the nurse determine if risk are present?  Or, does the surveyor who arrives and reviews the incident determine that the individual was at risk?  The fact is, the level of risk for the individual is usually not determined by anyone until the incident occurs.  

The standard routine for most facilities is rounds are made and the staff find that a resident is missing.  This may be the first time the resident has ever gone missing.  The staff calls administration, or the QIDP.  They discuss it.  The administration and others may go out and start looking around the area.  They go to local stores, parks, schools, and even check with neighbors.  In the end, the resident is usually found safe or even brought back to the facility by local law enforcement.  Most facilities let out a sigh of relief because the person was found within eight hours and they never look further at the standard.  Later, a surveyor shows up and reads about the incident in an exam report, or even a QIDP note.  The surveyor goes and looks further and finds no assessments for the resident's ability to move around the community.  The surveyor then goes and talks to the resident and determines that the resident was in an unsafe situation and that the facility failed to call in the allegation.  Boom!  There's your first tag on your 2567!  

So how can a facility prepare for the day a resident decides to take a walk?  There are actually several things a facility can do:
1.  If a guardian is involved, have them indicate what they desire for the resident.  In other words does the guardian know any reason the person would be unsafe going to a store alone should they leave the facility. 
2.  Develop a community based assessment- does the resident know about looking for traffic before crossing a street, does the resident know about red lights and crosswalks, what type of community do you live in - rural with few traffic issues, or next to an interstate with major traffic?  
3.  Have the IDTeam review and if necessary develop a plan to deal with "walks" or "elopements".
4.  Have facility policies specifically stating what the facilities view is on residents leaving.  

If the facility is completely honest, there will likely be a list of residents who can go out and easily come back on their own with no concerns.  There will also be a list of residents who should not be out on their own without supervision.  There may even be a list of residents that can do well in known areas, but not in unknown areas.  If you have a list, assessments, and IDTeam's reviews  and find that you face a surveyor who decides an individual can not be out safely from the facility, then you can present that information to the surveyor and be prepared if necessary to do an IDR for any tags cited. 

I recently had a resident in a facility who would walk to the store at the end of the block.  He would do this daily, especially when he had spending money.  He would go into the living room, announce to the staff that he was going to the store, and he would walk to the store.  Within about twenty to thirty minutes he would come back.  Assessments indicated he had the ability to safely move through the neighborhood, the IDTeam had reviewed it, and he had a service goal indicating that he could walk to the store.  The goal also indicated that he was usually only gone for about thirty to forty-five minutes.  During the time this individual lived in the home, survey arrived.  The surveyor questioned me about the individual and I provided the information.  She reviewed it and moved on to the next concern.  We received no deficient practice; however, I feel strongly that if we had not had the assessment and the IDTeam review, there would have been greater concerns expressed and to be honest there would be good reason for those concerns.