Failure to Safely Manage Community Pass for Dependent Quadriplegic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure the safety and adequate supervision of a dependent resident during a community pass. The resident was a quadriplegic, paralyzed from the neck down, dependent on staff for all care, and required a mechanical lift for transfers. Her assessments documented extensive care needs, lack of cognitive impairment, and that she was not capable of unsupervised outside pass privileges. A Community Survival Skills assessment indicated she was not sufficiently able to navigate safely in the community, and several items related to self-harmful behavior, adherence to pass policies, and following rules could not be determined. The discharge planning review identified that her physical and mental health problems increased her vulnerability and that she would likely suffer from lack of proper care and could become a victim or perpetrator of abuse/neglect in a less structured setting. Despite these documented limitations, the resident left the facility on a community pass with a male individual described by staff as her boyfriend or ex-boyfriend, who had reportedly just been released from jail or prison. Staff accounts show that earlier in the day the resident repeatedly stated she was going to leave and that her boyfriend was coming to get her. In the evening, after dinner, the man arrived, and staff assisted the resident with putting on her coat and preparing to leave. Staff questioned whether the man understood that the resident was paralyzed from the neck down and required complete care, and he reportedly stated he was aware of her care needs. Staff observed him take her out of the building and wheel her across the street to a city bus stop, and they expressed concern among themselves about who would be caring for her once she left. No medications were sent with her, and there was no physician order in place authorizing community access. The facility’s documentation and communication around the resident’s departure were incomplete and inconsistent. The sign-out sheet at the facility entrance contained an undated sign-out for the resident with an illegible signature for the party accepting responsibility, and the resident’s record contained no notes on the day she left indicating that she was going out on pass, with whom she left, or when she was expected to return. Nursing staff reported varying understandings of curfew expectations, with references to an 8 p.m. return time and an alleged agreement with the Administrator for a midnight return, but there was no clear documentation of these arrangements. When the resident did not return, staff discussed among themselves that she had called saying she would be back by midnight and that if she did not return she should be admitted to a hospital, but there was no indication in the record that law enforcement or family were promptly notified. The Administrator and charge nurse later stated that staff should have contacted the non-emergency police line and family when the resident failed to return, but this was not documented as having occurred. The resident ultimately did not return to the facility and was later admitted to an acute care hospital with a diagnosis including fluid overload.
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