Resident Denied Re-Entry After Authorized Out on Pass
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by denying re-entry to a resident who returned from an authorized out on pass (OOP). The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was accustomed to leaving the facility on day passes. On the incident date, the resident returned after midnight and was not allowed back into the facility, as staff were instructed by the nurse practitioner (NP) to consider the resident as having left against medical advice (AMA) and to direct him to the emergency room. The resident was not previously informed that returning after midnight would result in being locked out, and the facility's records included a physician's order permitting OOP without a specified curfew. Nursing notes document that the resident arrived at the facility, was informed of the NP's order, and was left outside the facility door. Police were called and, after determining there was no medical reason to send the resident to the emergency room and that he had established residency, instructed staff to allow the resident back inside. The resident was eventually let back into his room after several hours outside. The facility's policy on resident rights and responsibilities was reviewed, but there was no evidence that the resident had been made aware of any curfew or restriction related to OOP returns.