Failure to Obtain Physician Order for Resident Leave of Absence
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for a leave of absence (LOA) from the facility. According to the facility's policy, each resident leaving the premises, except for transfers and discharges, must be signed out. Review of documentation showed that a resident with multiple diagnoses, including hypertension, cerebral infarction, arthritis, history of falling, diabetes, schizophrenia, and substance abuse, left the facility on at least two occasions for LOA visits with her sister. Nursing notes and a physician's note confirmed these absences and the resident's return to the facility. However, a review of the resident's physician orders for the relevant month did not include any order authorizing the LOA. During an interview, the Nursing Home Administrator acknowledged that there was no physician's order approving the resident's absences. This failure to obtain and document a physician's order for the LOA was not in accordance with facility policy and regulatory requirements.