Failure to Ensure Competent LOA Process Resulting in Unmonitored Resident Absence
Penalty
Summary
Facility staff failed to maintain competency in the nursing aide proficiency related to leaves of absence (LOA), resulting in a resident leaving the facility for approximately three days without the knowledge of family or nursing staff. The resident involved had a history of stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and had a BIMS score of 7/15 indicating moderate cognitive impairment. He required assistance with all activities of daily living and, prior to the incident, was his own decision maker, as the power of attorney (POA) documents were not executed until after his return. On the day of the incident, the resident left the facility at approximately 2:00 p.m. with a person identified as a cousin, who signed the resident out on the facility’s LOA sign-out sheet. CNA staff assisted the resident in leaving, despite not having been trained on the LOA process. The Manager on Duty observed the resident leaving with the family member and was told by both the cousin and the resident that he had been signed out and would be going to a cookout and returning later that evening. LPN staff were informed, via another CNA, that the resident would return around 7:00 p.m., and this information was passed in shift report, but no further verification or follow-up occurred when the resident did not return as expected. The facility’s LOA policy required that the patient or responsible party notify a licensed nurse prior to leaving, provide an estimated time of return, receive medications, and have the LOA documented in the medical record, with additional notification to administrative staff if the resident would not return the same day. In this case, the resident left with a family member without medications and without a documented plan consistent with policy requirements. The resident’s departure was not recognized as a problem until the following day when an LPN noted that he had not returned to receive medications and contacted the resident’s daughter, who reported that the family had not removed him and was unaware of his whereabouts. No initial or 5‑day follow‑up report of the incident was submitted by the facility to the state agency as required by law.
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