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2. The 12/18/21 Emergency Medical Services Patient Care

Report indicates the call for services was made at 21:07.54
after the resident was located outside.
3. A Resident Incident and Accident Report dated 12/18/2021,
time of incident 8:20 p.m., read “went to get Resident to give
medications, couldn’t locate [him/her]. Asked another staff
member to help locate, when we couldn’t locate writer called
another staff member who called Administrator. Extra staff
came in to help locate Resident. [He/She] was found at 8:40
PM outside in the snow. While writer was calling EMT staff was
getting blankets and wrapping [him/her] up to keep [him/her]
warm and comforting [him/her] til(sic) EMT arrived.”
4. 12/18/2021 2145-hour Incident Note in Point Click Care (PCC)
read “Writer went to give medication to resident and could not
locate [him/her], asked staff member if [he/she] has seen
[him/her] and [he/she] replied no. Writer asked staff member to
search one hall and writer was looking in the other hall, we
could not locate [him/her]. Writer and staff once again went
down to each room, checking bathrooms and closets and beds
trying to locate resident. Writer called another staff member
who then called administrator to let [him/her] know that we were
trying to locate resident. A couple other staff members came to
help locate resident. Resident was found out in the court yard
in the snow around 8:40pm. Three staff members were
gathering blankets while another staff member stayed with
resident comforting [him/her] and wrapping [him/her] in
blankets while writer called EMS.”
5. 12/21/21 at approximately 12:40 p.m. DLC Surveyors
interviewed the CRMA staff working 2nd shift on 12/18/2021.
The CRMA stated he/she had witnessed the resident exit
seeking at dinner time on 12/18/2021. The CRMA stated the
resident had a history of elopement from the facility. The CRMA
noted the resident was missing later in the evening when
he/she went to administer medications to the resident.

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6. 12/21/21 at approximately 2:15 p.m. DLC Surveyors

interviewed the PSS staff working 2nd shift on 12/18/2021. The
PSS stated the courtyard door was locked that day and he/she
had let a resident out into the courtyard before dark earlier in
the day. When the resident came back into the facility, the PSS
shut and locked the door. The PSS staff stated he/she could
not remember shutting the door completely when the resident
returned. The PSS staff stated Resident attempted to get
outside earlier in the day when EMT was onsite at the facility
for a resident who had fallen.
7. Resident passed away on in a Hospice
facility in . The State of Maine Certificate of Death
filed on indicated Date of Date on .
Section 35: Immediate Cause of Death:
. [related to elopement]

5.25 Mandatory report of rights violations. Any person or

professional who provides health care, social services or
mental health services or who administers a long-term care
facility or program who has reasonable cause to suspect
that the regulations pertaining to residents’ rights or the
conduct of resident care have been violated, shall
immediately report the alleged violation to the Department
of Human Services ((800) 383-2441) and to one or more of
the following:

Disability Rights Center (DRC), pursuant to Title 5 M.R.S.A.

§ 19501 through § 19508 for incidents involving persons
with mental illness; the Long Term Care Ombudsman
Program, pursuant to Title 22 M.R.S.A. § 5107-A for
incidents involving elderly persons; the Office of Advocacy,
pursuant to Title 34-B M.R.S.A. § 1205 for incidents
involving persons with mental retardation; or Adult

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Protective Services, pursuant to Title 22 M.R.S.A. § 3470

through § 3487.

Reporting suspected abuse, neglect and exploitation is

mandatory in all cases. Documentation shall be maintained
in the facility that a report has been made.

Mandated reporters shall contact the Department of Health

and Human Services ((800) 383-2441) immediately after
receiving and/or obtaining information about any rights
violations. [Class IV]

This has not been met as evidenced by:

Based on record reviews and interviews, the facility failed to report a

suspected violation of the conduct of a resident’s care to the
Department of Health and Human Services (800) 383-2441), the
Division of Licensing and Certification and to one or more listed entities
in Section 5.25, (e.g., Adult Protective Services).

Finding:

Facility documentation and staff interviews confirmed the facility was

aware of a conduct of resident care violation on 12/18/21 (Resident
. There was no evidence of a mandatory report sent to the
Division of Licensing and Certification and to one or more listed entities
in Section 5.25 (e.g., Adult Protective Services).

On 12/21/2021 Administrator confirmed the 12/18/2021 incident was

not reported to the Division of Licensing and Certification and one to
one or more listed entities in Section 5.25

10 ADMINISTRATION

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10.9 Administrative responsibilities. The administrator is

responsible for the overall operation of the facility.
Notwithstanding Section 10.1, the administrator shall perform
the following duties:

10.9.4 Develop, maintain and carry out written policies and

procedures to implement these regulations. Other
policies may be developed at the discretion of the
facility to ensure the orderly conduct of resident care.
Policies shall indicate what staff are responsible for
coordination or implementation of policies and
procedures. Required policies include:

10.9.4.1 Resident care;

This has not been met as evidenced by:

Based on record review and interview, the facility failed to follow their
Resident Care/Missing Resident Policy Implementation Step 3 and
Step 5 on 12/18/2021 when a resident was discovered to be missing
from the facility.

Finding:

Woodlands Memory Care of Rockland Resident Care/Missing

Resident Policy and Implementation states:

POLICY

Staff will investigate all reports of missing residents according to the

missing resident plan to enable a missing resident to be found as
quickly as possible and to maintain the resident’s safety, dignity, and
privacy.

IMPLEMENTATION
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When an employee discovers that a resident is missing from the

facility, he/she will:

1.Determine if the resident is out on authorized leave or pass. If not;

2.Notify the person in charge.
3.The person in charge will notify the police department (Call 911) that
a resident may be missing and that our staff will begin searching the
building. Give the police as much information as possible.
4.Assign staff person(s) to make a thorough search….All staff will
report back to the person in charge within 10 minutes if resident is not
located in their specific search area. If resident not located;
5.Notify the police department (911) that our search of the immediate
building was unsuccessful.

Facility staff failed to notify the police department when a resident was
initially discovered to be missing and when an initial search of the
immediate building was unsuccessful. Facility staff made a call to
(911) when the resident was found and presented with need for
medical attention.

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