Failure to Document Physician's Order for Resident Out on Pass
Penalty
Summary
The facility failed to ensure that the clinical record for one resident was complete and accurate when there was no written physician's order for an overnight out on pass before the resident left the facility. The resident, who had diagnoses including spinal stenosis and difficulty walking, was assessed as self-responsible with intact cognition but required partial to moderate assistance with several activities of daily living. Despite these needs, the resident left the facility for an overnight pass with a family member without a documented physician's order authorizing the absence. Upon review, there was no active physician's order for the overnight pass in the resident's medical record. Progress notes indicated that a nurse claimed to have obtained a verbal order from the physician but failed to document or carry out the order due to being in a hurry. The physician later stated he would not have given such an order and could not recall if he had authorized the pass. Facility policy required that a physician's order be documented for any out on pass, and that telephone orders be recorded with date, time, and signature at the time the order is taken. The resident returned to the facility with multiple injuries, including abrasions, bruises, and bleeding on the back of the head, and was noted to be intoxicated. The resident was subsequently sent to a hospital and diagnosed with alcohol intoxication and a closed head injury. The lack of a documented physician's order and assessment prior to the resident's absence resulted in an incomplete and inaccurate clinical record.