Failure to Complete Therapeutic Pass Documentation for Resident
Penalty
Summary
The facility failed to follow its policy and procedure regarding residents leaving and returning from therapeutic passes for one of three sampled residents. Specifically, for a resident with diagnoses of schizophrenia and epilepsy, the required Out On Therapeutic Pass/Leave of Absence forms were not properly completed on multiple occasions. The forms lacked the signature of a licensed nurse, did not indicate the date and time of the resident's return, and did not include the name of the person signing the resident back into the facility. This failure meant there was no documentation that a licensed nurse had assessed the resident's stability before leaving or upon return, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy mandates a licensed nurse to sign the form both when a resident leaves and returns, to verify the resident's condition and ensure their safety. The incomplete forms did not provide a system to ensure the resident's safe release or return, and staff acknowledged that without proper documentation, there was no proof of assessment or verification of the resident's whereabouts. The facility's policy review further confirmed that all residents leaving the premises must be signed out and in, with expected times of return documented.