Failure to Ensure Resident Safety After Missed Return from LOA
Penalty
Summary
The facility failed to ensure the safety of a resident who did not return in a timely manner after a leave of absence (LOA). The resident, who had diagnoses including chronic obstructive pulmonary disorder, diabetes, and congestive heart failure, was cognitively intact and independent in transfers. His care plan allowed for unsupervised outings in his powerchair, and he routinely took public transportation to visit a nearby city, always returning before midnight. On the day in question, the resident signed out at 11:55 A.M. but did not return by midnight as expected. Staff actions were inconsistent with facility policy and expectations. The LPN on duty noted the resident's absence late at night, attempted to call his cell phone without success, and texted the DON, who instructed her to call local hospitals. However, the LPN did not follow through with these instructions, citing being too busy and assuming the day shift would handle it. There was no evidence that the resident's emergency contacts or local hospitals were called during the night. The DON was not updated until the following morning, at which point it was discovered that the resident had passed away at a hospital after being brought in from a grocery store. Interviews with staff revealed uncertainty about the care plan and the appropriate steps to take when a resident did not return from an LOA. The facility's policy required documentation of the resident's departure, destination, and expected return time, as well as staff knowledge of the resident's whereabouts. Despite these requirements, the lack of timely follow-up and communication contributed to the failure to ensure the resident's safety after he did not return as anticipated.