Incomplete Documentation on Resident Out on Pass Logs
Penalty
Summary
The facility failed to ensure that the Resident Out on Pass Log was accurately and completely filled out for two of four sampled residents. For both residents, multiple entries on the Out on Pass Log were missing critical information, including the time the resident went out, the time they returned to the facility, and the nurse's initials. These omissions were identified through a review of the medical records and facility documents, which showed repeated instances where required documentation was left blank on several dates for both residents. Facility policy requires that nursing documentation be concise, clear, pertinent, and accurate, and that all resident information be entered in the appropriate section of the clinical record following established guidelines. The Out on Pass policy further specifies that residents or their responsible persons must sign out and back in on the log, and that nurses are to sign the entries. During interviews, the DON confirmed that the logs for the two residents had blank entries and acknowledged that nurses were supposed to sign the log. The Administrator and DON both acknowledged these findings during the survey.