In addition to the fine, High Chase LLC agreed in a consent order with the state Department of Public Health (DPH) to implement new policies and procedures for staff to follow when a resident goes missing. The facility’s licensee denied the DPH’s allegations, but signed the order without any formal challenge of the allegations.
Officials at High Chase did not return calls seeking comment this week.
The fine and consent order stem from an incident discovered during a December 2016 inspection. DPH investigators found that a resident diagnosed with depression and suicidal ideation went missing from the facility for two days last November and staff did not take proper actions, according to a DPH citation included with the consent order.
The resident was seen smoking outside the facility at 8 p.m. Nov. 26, having returned to High Chase earlier that day from a leave of absence. On Nov. 27, staff went to get the resident for breakfast but the resident was gone. Staff did not see the resident at all that day, according to the citation.
On Nov. 28, facility documentation shows staff questioned other residents and contacted the missing resident’s family to try to determine the resident’s whereabouts. The resident’s family subsequently contacted police and reported the resident as a missing person, according to DPH.
The resident was found deceased in an area pond Nov. 29, according to the citation.
Residents are free to come and go at High Chase, but documentation showed it was unusual for the resident not to notify staff or sign out when leaving for a full day, investigators found.
According to DPH, documentation failed to show that staff took any action when the resident went missing. Logs showed the resident did not receive medications on Nov. 27 and Nov. 28, but staff didn’t follow up.
When interviewed by DPH, a facility administrator said staff is required to do a head count of all residents each morning. The administrator also said there was no policy in place for staff to follow when a person goes missing, according to the citation.
The administrator spoke to the staff that worked Nov. 26-28 but did not document any staff statements or implement any interventions as a result of what happened, DPH found. Under the consent order, DPH directed High Chase to train staff in new policies and procedures that address what to do when a resident is missing and how to report such instances.
