Failure to Obtain OOP/LOA Orders and Update Care Plans for Resident Leaves
Penalty
Summary
Surveyors determined that the facility failed to obtain a physician order (PO) for one resident to go out of the facility on pass (OOP) or take a leave of absence (LOA), and failed to include OOP/LOA status and related interventions in the care plans of two residents. Observations in the lobby showed residents interacting with the Receptionist, who controlled the front door. The Receptionist reported that only one resident was allowed to leave independently and that nursing staff would call her when this resident was coming to the lobby to go out, after which she would assist the resident with getting their wheelchair through the front doors. For the first resident, medical record review showed admission with diagnoses including injury from a motor-vehicle accident and polyneuropathy, with a Quarterly MDS indicating intact cognition (BIMS score of 15) and use of a motorized wheelchair or scooter. The Resident Responsibility/Sign Out Sheet documented multiple instances in which this resident signed out of the facility, listing self as the responsible party. However, the Order Summary Report contained no PO authorizing OOP or LOA or specifying the level of supervision required, and the Care Plan Report contained no focus, goals, or interventions related to the resident going OOP or on LOA. In an interview, this resident stated they went out independently once or twice a week, notifying a nurse, signing out in a logbook, and then having the nurse notify the Receptionist to unlock the front door. For the second resident, the Admission Record documented diagnoses including cellulitis of a limb, benign neoplasm of the meninges, cirrhosis of the liver, generalized muscle weakness, and difficulty walking, with a Comprehensive MDS showing intact cognition (BIMS score of 14). The Order Summary Report for this resident did contain POs allowing LOA with medications and LOA with a responsible party, each with specified start dates. Despite these orders and the resident’s report that they had gone out with family in the past, the Care Plan Report lacked any focus, goals, or interventions related to going OOP or on LOA. In an interview, the DON confirmed that the first resident did not have a PO for OOP/LOA and stated that such an order and corresponding care plan information were necessary so staff would know if and how the resident could go out, consistent with the facility’s Comprehensive Care Plans policy and professional standards of quality.
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