Failure to Care Plan for Residents Leaving on LOA or AMA
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing leave of absence (LOA) and leaving against medical advice (AMA) for two residents. For one resident, the record included a signed "Determination to Leave the Facility Against Medical Advice" form, which stated the resident was not cleared by the physician to leave due to being at high risk for accidents, falls, or other acute illness/conditions when outside the facility unsupervised, potentially resulting in serious negative health outcomes. The form documented that the resident was their own responsible party, not deemed incompetent, and that they had participated in care planning related to the decision to leave unsupervised and agreed to abide by the plan of care, with plans to be reviewed and revised as needed. However, review of the resident’s care plans showed no care plan addressing the decision to leave AMA or go on LOA, and there was no documentation that the resident had actually participated in care planning related to this decision. For the second resident, the face sheet showed admission to the facility and an MDS with a BIMS score of 13/15, indicating intact cognition. LOA sign-out sheets showed this resident frequently left the facility on LOA. Despite this, review of IDT notes revealed no discussion regarding the resident’s LOA or evaluation of safety, and review of the resident’s care plans showed no care plan addressing LOA, safety interventions, or assessments. In an interview, the DON stated she did not find an evaluation of this resident’s ability to go on LOA or any IDT documentation regarding LOA ability, and she stated her expectation was that evaluation and care planning be completed for a resident who goes on LOA. The facility’s policy dated 11/16/2022 required that a corresponding care plan be developed and initiated for LOA, addressing clinical issues such as medication needs during leaves, education on medication administration, dietary issues, and any other potential concerns or problems, which was not done for these residents.
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