F0658

D

Failure to Follow Out-on-Pass and GT Wound Management Policies

Bakersfield, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its “Out on Pass” policy for a cognitively intact resident with significant physical limitations and an unresolved surgical wound. The resident’s MDS showed a BIMS score of 13, functional limitations in range of motion on one side of both upper and lower extremities, wheelchair dependence, inability to walk, and a need for supervision or touching assistance with transfers and setup assistance for wheelchair mobility. A medical progress note documented a history of need for assistance with personal care and generalized muscle weakness, with comments indicating a need for supervision and care 24 hours a day. The resident reported having all toes amputated on the right foot, with a healing surgical wound, and was observed with a dry dressing wrapped around the right foot.

Record review showed that the resident purchased a vehicle and was leaving the facility without a physician out-on-pass order. The order summary report confirmed there was no physician order for out on pass. The facility’s out-on-pass log for the month showed multiple instances where the resident signed out but did not sign back in on return. Staff interviews revealed that the resident had been seen using marijuana in the facility and driving his car, with the social services director stating the resident had almost hit several cars in the parking lot. The DON and social services director both stated the resident would leave without notifying licensed nurses, preventing timely notification of the physician, and the DON confirmed the resident did not have a physician order to go out on pass.

Further review of nursing notes showed that on one occasion the morning nurse reported the resident had signed out in the afternoon, was seen leaving during rounds, and had not returned by the time of the evening medication pass, with a later note documenting the resident’s return. The DON stated the resident was not assessed by a licensed nurse prior to leaving or upon returning to the facility, despite the facility’s written policy requiring a licensed nurse to assess the resident’s physical and mental status before leaving and to reassess upon return. The DON acknowledged that the policy, which also requires a physician order for passes and verbal notification to a licensed nurse before leaving, was not followed.

The deficiency also includes the facility’s failure to follow its wound management policy and physician orders for treatment of a resident’s gastrostomy tube (GT) site. On admission, nursing documentation indicated the resident had a GT with skin irritation. The physician’s order summary directed staff to cleanse the GT site with normal saline, pat dry, apply zinc oxide to the peri-wound area, cover with a T-drain sponge, and secure with tape every shift. However, the treatment administration record showed the ordered treatment was only being performed on the day and evening shifts, not every shift as ordered. The treatment nurse confirmed the order was not followed and that there was no physician order to monitor the GT site as needed.

During observation, the resident’s GT dressing was black, did not cover the insertion site, and the GT site was red and leaking yellow liquid. The treatment nurse stated the dressing was wet from leaking GT formula and that the moisture was causing irritation and redness around the site, and also stated the GT site should have been monitored as needed to keep it clean and dry. A CNA reported seeing the resident earlier with a black dressing that did not cover the GT site and acknowledged she did not notify the treatment nurse or any licensed nurse, stating she should have done so. Review of the care plan showed there was no care plan developed to address the skin irritation at the GT site, despite the DON stating the irritation was caused by leaking GT formula and that there should have been a care plan to monitor when the dressing needed to be changed. The facility’s wound management policy required a licensed nurse to perform skin assessments and develop a care plan based on physician recommendations, and the DON stated this policy was not followed.