Resident Allowed Out on Pass Without Written Physician Order
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including spinal stenosis and difficulty walking, was allowed to leave the facility on an overnight pass without a written physician's order. The resident was assessed as self-responsible with intact cognition but required partial to moderate assistance with several activities of daily living, including mobility and hygiene. Review of the resident's records showed no documented physician's order for the overnight pass, and the facility's policy required such an order to be written and documented by a licensed nurse. The nurse responsible for the resident's care stated that a telephone order was obtained but admitted to not documenting it due to being in a hurry. The attending physician later stated he would not have given such an order and could not recall if he had done so. Upon returning to the facility, the resident was found with abrasions and bruises on both arms and legs, as well as bleeding on the back of the head, and appeared intoxicated. The resident was subsequently sent to a hospital and diagnosed with alcohol intoxication and a closed head injury. Facility policy required that out-on-pass orders be documented and specify if the resident needed to be accompanied, but this was not followed in this instance, leading to the deficiency.