Failure to Prevent Unauthorized Resident Exit and Report Incident
Penalty
Summary
A resident with a history of joint replacement surgery, stimulant dependence, schizoaffective disorder, generalized muscle weakness, and abnormal posture left the facility without an approved out-on-pass (OOP) order. The resident's care plan required one-person assistance for ambulation and locomotion, but this intervention was not implemented, allowing the resident to exit the facility unassisted. The resident was later found to have walked to a nearby store, rested outside, and returned to the facility on his own, stating he was unaware that a physician's approval was needed for an OOP. Facility records and staff interviews confirmed that there was no OOP order in place for the resident at the time of the incident. The facility's policy required a practitioner’s order for therapeutic leave, which was not obtained. Staff became aware of the resident's absence when he missed his scheduled medication, and a search was conducted, including contacting the police. The receptionist, responsible for monitoring the front entrance, observed an individual leaving but was unable to confirm the resident's identity or prevent the exit. Additionally, the facility failed to report the incident as an unusual occurrence to the California Department of Public Health (CDPH), as required by both facility policy and regulatory standards. The Director of Nursing confirmed that the incident was not reported, despite the policy mandating the reporting of events affecting the health, safety, or welfare of residents.