Failure to Maintain Complete Clinical Records for Resident Out on Pass
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible clinical records for a resident who went Out on Pass (OOP) with a family member. The resident, who had a diagnosis of schizoaffective disorder and alcohol dependence and was under the care of a public guardian, had an approved OOP request for a specific date and time, as indicated by the Conservatee Leave Request form. However, upon review, the resident's clinical records did not contain the required OOP Request Form or the document titled 'Signing Residents Out on Pass' for the date in question. Interviews with facility staff, including the Social Services Assistant, Registered Nurse, Medical Records Assistant, and Director of Nursing, confirmed that the OOP Request Form, which should be signed by the Program Director, Social Services Director, and DON as part of the interdisciplinary team assessment, was missing from the resident's chart. Facility policy requires that the OOP Request Form be completed and signed by the appropriate team members to ensure the resident's safety and compliance with program requirements before leaving the facility. The absence of this documentation meant that the necessary assessment and authorization process was not properly documented or followed for the resident's OOP. This deficiency was identified through interviews and record reviews, which consistently indicated that the required documentation was not present in the resident's clinical records for the specified OOP event.