Resident Excluded from Person-Centered Care Planning After OOP Incident
Penalty
Summary
The facility failed to ensure that a resident was included in the development and implementation of his person-centered plan of care following an incident related to his return from an Out on Pass (OOP) leave. The resident, who had a history of multiple fractures and was cognitively intact and independent in activities of daily living, was denied re-entry to the facility after returning late from a day pass due to unforeseen circumstances. The resident reported not being informed of any rule that would prevent him from re-entering the facility after midnight, and he was only allowed back inside after contacting the police several hours later. A review of the resident's medical record showed a physician's order permitting OOP and no evidence of cognitive impairment. However, there was no documentation of an Interdisciplinary Team (IDT) meeting or care conference following the incident, despite facility policy and staff statements indicating that such meetings should occur quarterly and after significant events or changes in condition. The last documented IDT for the resident was several months prior to the incident, and there was no record of the resident refusing participation in an IDT. Interviews with facility staff, including the Social Service Director, Assistant Director of Nursing, and a licensed nurse, confirmed that no IDT was conducted after the incident. Staff acknowledged that IDTs are essential for collaborative care planning and updating care plans to reflect changes or address issues. The absence of an IDT meant that the resident was not involved in reviewing or updating his care plan after the incident, contrary to facility policy and resident rights.