Failure to Follow LOA Procedures Resulting in Unmonitored Resident Departure
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and follow its Leave of Absence (LOA) policy for a cognitively intact resident, resulting in the resident leaving the building with family without the facility’s knowledge of their whereabouts. The resident had been admitted with leukemia and pneumonia, had intact cognition per the MDS, and was independent with ADLs including ambulation. An elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. However, there was no physician order, no care plan, and no documentation in the electronic health record authorizing or describing an LOA for this resident at the time they left the facility. On the evening in question, the resident was seen on the front door camera properly dressed and walking out of the facility with several family members at approximately 6:00 PM. The receptionist did not recall seeing anything unusual and did not remember seeing the resident leave, despite a sign at the exit instructing visitors to sign residents out when leaving. The facility did not have information on who the resident left with, where they were going, or how long they would be gone, and the resident was not listed in the receptionist’s elopement book. The resident did not return to the facility as expected, and the next morning it was reported in the morning meeting that the resident had not come back from what staff believed was an LOA. Staff interviews revealed that both nursing and CNA staff assumed the resident was on an LOA without verifying orders or documentation. An LPN stated that a CNA had told her the resident went on an LOA with family, but she did not check for an LOA order, did not confirm who the resident was with, and did not report the resident’s absence until the end of her shift. A CNA reported that when she went to pick up the resident’s dinner tray, the resident was not in the room and had earlier been with several visitors; she assumed the resident had gone somewhere with them and did not recognize the situation as a potential elopement, nor did she initiate an elopement response. The facility’s LOA policy required physician orders, care planning, sign-out/sign-in procedures, and implementation of elopement protocol if a resident left without the facility’s knowledge and whereabouts were unknown, but these procedures were not followed in this case.
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