Resident Rights Restricted by Automatic No-LOA Orders and Unclear Leave of Absence Process
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s rights to self-determination and to exercise the right to take a leave of absence (LOA) without undue interference. One resident admitted with a right femur fracture and diabetes was alert, oriented, able to make needs known, and assessed as not at risk for elopement. The resident’s care plan anticipated discharge home in several weeks, and the admission MDS documented that going outside for fresh air in good weather was somewhat important to the resident. Despite this, a standing physician order entered at admission directed that the resident may not go out on LOA. The facility’s practice, as described by multiple staff, was to enter automatic “no LOA” orders for all residents upon admission, both short-term and long-term. Staff, including LPNs, RNs, social services, and PT, consistently reported that residents could only leave on LOA if they specifically requested it, at which point nursing would contact the physician/APRN for a one-time LOA order and then require a PT assessment before the resident could leave. Staff also indicated that this process could take a day or more and that the electronic medical record defaulted to no LOA orders for all residents. One nurse and a unit manager stated that the rationale for this automatic restriction was related to insurance reimbursement. The resident interviewed stated a desire to go on LOA to visit grandchildren and reported not being aware that LOAs were allowed. Review of the facility’s Welcome Book showed it referenced LOAs and directed residents to pages 2–3 of the Admissions Agreement for more information, but the Admissions Agreement pages were not numbered and did not contain the referenced information about LOA privileges or the requirement to request LOA 24 hours in advance. The Admissions Agreement did include a clause about the facility assuming no responsibility for injury or deterioration while a resident is temporarily absent, but there was no clear, accessible explanation of LOA rights or procedures. The DNS and ADNS confirmed there was no written LOA policy, only a process in which all residents received no LOA orders at admission and had to obtain physician approval and PT evaluation before any LOA, which interfered with the resident’s ability to exercise the right to leave the facility.
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