Failure to Revise Care Plan for Out on Pass Privileges
Penalty
Summary
The facility failed to revise the care plan for a resident who had a physician's order to leave the facility on an Out on Pass (OOP). The resident, who had multiple fractures of the pelvis and right ribs and used a manual wheelchair, was not informed of any time restrictions or rules regarding re-entry to the facility after leaving on a day pass. On one occasion, the resident was denied entry back into the facility after midnight due to facility rules that had not been communicated to him, resulting in him being locked out for three hours until police were called. There was no documentation of an Interdisciplinary Team (IDT) meeting or care plan revision following this incident. Review of the resident's care plan showed it had last been updated months prior to the incident and did not reflect the current situation or address the specific circumstances of the resident's OOP privileges. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan was not updated after the incident, and staff were unclear about the rules and interventions to be applied. The facility's policy required the care plan to be reviewed and revised by the IDT, but this was not done in response to the incident.