Failure to Follow Out-on-Pass Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to follow its own policy and procedure regarding residents going out on pass (OOP) for three sampled residents. Specifically, OOP orders for these residents did not indicate whether the residents could leave unaccompanied by a responsible person or specify the length of time they were permitted to be out. For example, one resident with moderate cognitive impairment and physical assistance needs had an OOP order that did not clarify if accompaniment was required or the duration of the pass. Another resident's OOP order allowed them to go out with a family member but did not specify the length of time for the pass. A third resident's OOP order also lacked information on accompaniment and duration. Additionally, the facility did not ensure that residents were assessed before and after going out on pass, as required by policy. For one resident, there was no documentation of an assessment to determine stability prior to leaving or upon return. Staff interviews confirmed that assessments should be conducted to establish a baseline and ensure safety, but these steps were not documented or performed as required. The Director of Nursing acknowledged that the facility's policy was not followed, noting that OOP orders were missing critical information such as accompaniment requirements and duration, and that assessments before and after OOP were not documented. The facility's policy clearly states that in the absence of a specific order allowing unaccompanied leave, a responsible person must accompany the resident, and that licensed nurses must assess and document the resident's condition before and after OOP. These procedures were not adhered to for the residents in question.