Failure to Verify Escort Identity for Supervised Community Pass
Penalty
Summary
The facility failed to follow its protocol for supervised community passes by not verifying the identity of the individual who signed out a resident for a community pass. Specifically, a resident with a significant history of substance abuse, multiple injuries, and a care plan indicating she was not capable of unsupervised outside pass privileges was allowed to leave the facility. The pass request form listed a specific individual as the escort, but the ID scanned and attached did not match the name on the form. Staff interviews revealed that the process for verifying the escort's identity was not followed because the receptionist, who was responsible for scanning the ID, was occupied with other duties and did not interact with the person taking the resident out. As a result, the resident left the facility on a supervised pass and did not return. The nurse on duty followed the process of scanning the ID and handing it to the receptionist, but the mismatch in identity was not caught. The facility's policy on community passes did not clearly outline the supervised pass procedure, contributing to the failure. The administrator confirmed that the police were not notified when the resident did not return, and did not consider the incident to be an elopement.