Failure to Assess and Care Plan Resident’s Safety for Independent Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to assess and implement individualized interventions to ensure safe independent community access for a resident with expressive aphasia and cognitive impairment. The resident had multiple diagnoses including stroke, bipolar disorder, aphasia, diabetes type II, anxiety disorder, cognitive symptoms, and encephalopathy. The admission MDS documented moderate cognitive impairment and noted that community ambulation abilities (such as navigating uneven surfaces, managing curbs/steps, and car transfers) were not assessed. The resident’s care plan identified independence with ADLs, transfers, and ambulation, and noted vulnerability due to communication impairment with interventions such as clear, simple instructions and visual prompts, but it did not address community outings or independent leave. Nursing notes documented multiple occasions when the resident left the facility independently for outings, with staff noting expected return times, but there was no documentation between the admission date and the survey period of any assessment of the resident’s ability to safely navigate community environments, manage emergencies, or obtain assistance while outside the facility. During observation and interview, the resident was seen ambulating independently and demonstrated use of a cell phone to call family members, but the contact list did not include the facility’s phone number or address. Staff interviews revealed inconsistent understanding and lack of clear criteria regarding which residents were safe to leave independently; CNAs and RNs relied on factors such as ability to walk, absence of a WanderGuard, or checking the care plan or provider orders, but they did not reference any standardized assessment tool. Clinical staff, including a speech therapist and occupational therapist, reported they had not been consulted to assess the resident’s safety for independent community access, despite the speech therapist expressing concerns related to communication and suggesting that written word lists could assist the resident. The vice president of clinical services described an informal approach using hospital history, elopement assessment, and cognition to determine safety, and stated she would document in the care plan if a resident was not safe to leave alone, but there was no such documentation for this resident. The nurse practitioner stated she would expect an assessment of cognition, mobility, and functional abilities such as crossing the street, using a bus, or handling money before a resident went out independently. Facility policies on resident leave of absence and comprehensive person-centered care planning did not include protocols or criteria for determining when residents could leave independently, contributing to the lack of a formal assessment and care plan interventions for this resident’s unsupervised community outings.
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