Failure to Develop Care Plan for Resident's Leave of Absence
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's ability to leave the facility under a physician's 'out on pass' order. The resident had physician orders allowing them to leave the facility for up to four hours and, later, to go out on pass with a responsible party. However, the resident's medical record did not include the name or contact information for the responsible party, nor did it contain a care plan specific to the resident's out on pass status. On review of facility documentation, it was found that the resident had left the facility on pass, as recorded in the Release of Responsibility for leave of absence log. During an interview and concurrent medical record review, an RN confirmed that the resident's medical record lacked information about the responsible party and that no care plan had been developed to address the resident's ability to leave the facility. This omission was verified by the RN during the review.