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F0550
D

Failure to Facilitate Resident's Right to Leave for Family Event

Carmichael, California Survey Completed on 12-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a licensed nurse failed to initiate necessary interventions to allow a resident to leave the facility for a Thanksgiving dinner with her family. The resident, who had diagnoses including major depressive disorder and general anxiety but no memory impairment, was denied the opportunity to go out because there was no Leave of Absence (LOA) order from a physician. The nurse did not attempt to contact the physician for an LOA order, citing instructions not to call doctors on weekends. As a result, the resident was not able to participate in the planned family event, despite expressing her desire to do so and her frustration at not being informed of the LOA requirement in advance. The resident's care plan identified her as being at risk for psychosocial well-being concerns and social isolation, with interventions to encourage socialization and minimize decline in mood and behavior. The Director of Nursing confirmed that the nurse should have attempted to obtain an LOA order and acknowledged that the resident was not included in preparations to secure LOA orders before the holiday weekend. Additionally, the facility did not provide a policy or procedure for obtaining LOA or out-on-pass orders when requested, despite having a policy affirming residents' rights to self-determination and access to persons and services outside the facility.

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