Failure to Follow Community Pass Policies and Involve Responsible Parties
Penalty
Summary
The facility failed to follow its own policies and procedures regarding community survival skill assessments, physician orders for community passes, and involvement of responsible parties or families when residents left the facility against medical advice. Multiple residents were allowed to leave the facility on independent community passes without proper assessments or physician orders, and in some cases, despite having restrictions in place due to prior non-adherence or substance abuse. Documentation shows that at least two residents left on independent passes and did not return, while others were allowed out without the required physician authorization or in violation of care plan restrictions. One resident with a history of schizophrenia, substance abuse, and prior incidents of not returning from passes was allowed to leave on an independent pass, despite only being assessed as suitable for supervised passes. The resident did not return, and the facility did not notify the family or provide adequate cooperation with law enforcement. The care plan did not address the resident's history of not returning from passes, and there was no evidence of a current community survival skill assessment or physician order supporting independent pass privileges. Additionally, the facility failed to notify the responsible party or family, even though social service notes indicated family involvement in the resident's care. Other residents were also affected by similar failures. One resident with a restricted pass due to non-adherence was able to leave the facility, and staff could not confirm if family or police were notified. Additional residents were allowed out on independent passes without proper physician orders, and their care plans did not reflect the necessary restrictions or assessments. The facility's own policies require community survival skill assessments upon admission and quarterly, physician orders for pass privileges, and involvement of responsible parties in cases of discharge against medical advice or missing residents, but these procedures were not consistently followed.