Failure to Establish Escort Screening Process for Resident Leave of Absence
Penalty
Summary
The facility failed to establish criteria or a screening process for determining the suitability of escorts for residents approved for an escorted leave of absence. According to facility policy, residents requesting a leave of absence must have a physician's order indicating the leave is safe, and if an independent leave is deemed unsafe, an escorted leave may be considered. However, the facility did not define the role or qualifications of a safe escort, nor did it have a process to screen or approve individuals serving as escorts. In the case reviewed, a resident with a history of opioid use disorder and drug and alcohol abuse was granted an escorted leave of absence by physician order due to a family emergency. The resident left the facility with a friend who was not listed as an approved visitor or contact in the resident's records. Nursing documentation indicated that the resident was expected to return the same day but did not return as scheduled. Attempts to contact the resident throughout the night were unsuccessful. The following day, the resident's daughter informed the facility that the resident had died from a drug overdose while on leave. Interviews with facility staff, including the administrator and LPN, confirmed that there was no established process to define or screen escorts for safety, and the individual who escorted the resident was not previously identified as a visitor or contact.