Failure to Evaluate Resident’s Safety for Leave of Absence
Penalty
Summary
Failure to complete and document an evaluation of a resident’s ability to take a leave of absence (LOA) occurred when a cognitively intact resident with known visual impairment was allowed to sign out on LOA without an assessment of safety. The resident had a BIMS score of 13/15, indicating intact cognition, and a care plan identifying impaired visual function related to stroke, but the care plan did not include any interventions addressing LOA safety in light of the visual impairment. Progress notes documented that the resident signed out on LOA with another resident and, upon return, did not use the crosswalk to cross the street and was struck by a speeding vehicle, resulting in a fractured spleen, rib fracture, and scalp laceration. The facility’s LOA policy required that affected residents be evaluated regarding their abilities at admission, quarterly, upon significant change in condition, and after any new developments that might warrant a change in the evaluation. The social worker reported she had heard that staff needed to know if a resident was safe to go out on LOA as their own responsible person and assumed there was an assessment form, but she had never seen or completed such an assessment. Review of the electronic medical record showed only one IDT meeting, which did not address LOA or evaluate the resident’s LOA safety, and the DON confirmed she could not find any LOA ability evaluation for the resident. No IDT meeting or LOA ability evaluation was conducted or documented after the accident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.