Failure to Implement Abuse and Unusual Occurrence Reporting Policies for Unauthorized LOA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and unusual occurrence reporting policies when a cognitively impaired resident left the facility on a leave of absence (LOA) and remained away for approximately three days without the knowledge of nursing staff or the resident’s family. The resident had diagnoses including stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and a recent MDS with a BIMS score of 7/15 indicating moderate cognitive impairment, with a need for assistance with all ADLs. At the time of the incident, the resident was his own decision maker, as the POA documents were not executed until after his return. On the day of the incident, the resident left the facility around 2:00 p.m. with a person identified as a cousin, who signed the resident out on the LOA sheet; staff, including an LPN and the Manager on Duty, understood that the resident was going to a cookout and would return later that evening. The report states that a CNA, who was not trained on the LOA process, helped the resident leave, which the Administrator later identified as an error. The resident did not return that evening as expected. The following day, an LPN became concerned when the resident was not back in the building to receive medications and called the resident’s daughter, who then learned for the first time that the resident was missing and that no family member had removed him. The facility’s abuse/neglect/misappropriation/crime policy required reporting unusual incidents or occurrences to the State Survey Agency, including events likely to result in legal action or involving law enforcement, and specified time frames for initial reporting and submission of investigative findings. Despite the resident being gone for approximately 72 hours and a missing person report being filed with local police, the facility did not submit an initial report or a 5‑day follow‑up report to the state agency as mandated by its abuse policy. The state agency instead received an anonymous complaint two days after the incident, with an addendum indicating that the resident himself later contacted the state agency after learning he had been deemed a missing person and expressed a desire to discharge and make his own decisions. The facility’s internal investigation was incomplete at the time of review; it lacked statements from residents and all involved individuals and did not clearly document the chronology of events leading to the incident. The Administrator and DON reported no additional information when interviewed, and the failure to follow the abuse and unusual occurrence reporting policy, along with allowing an untrained CNA to assist with the LOA, constituted the core deficiency.
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