I, {accompaniedBy}, as a representative of {residentsName}, a resident of Cold Spring Hills Center for Nursing and Rehabilitation, would like to take the resident on a leave out of the facility. I understand that there are added risks and hazards by leaving the grounds of the facility. I accept full responsibility for the resident while off facility property and agree to hold harmless Cold Spring Hills Center for Nursing and Rehabilitation from any liability.
I understand that the resident's attending physician and the interdisciplinary team must consent to my request
Iagree to abide by all the policies, procedures, and facility rules for residents leaving escorted.
Specifically, I agree to:
1. Exit and enter only through the front door;
2.Obtain a signed pass whenever I would like to take the resident out of the facility, and notify the unit nurse when the resident returns;
3. Leave a copy of the signed Escorted Out On Pass form at the Reception Desk;
4. Follow all care plan instructions and education provided to me by the facility. Should I forget a step or need guidance while out of the facility, I will call the nursing supervisor for assistance;
5. Carry a cellphone at all times and provide that number to the facility, in cases of emergency;
6. In the event of an emergency, I will call 9-1-1 for immediate assistance to the resident and notify the facility of the incident. I will provide any and all information related to the incident to the facility in compliance with NYS DOH and other governing and legal bodies;
7. Refrain from purchasing and bringing back any illegal or hazardous items for the resident along with food, beverages, cigarettes, smoking paraphernalia (including lighters or matches), illegal, or hazardous items for other residents;
8. Maintain the resident in appropriate attire for current weather conditions, and have them wear sunblock when appropriate or advised to do so;
9.Abide by any restrictions not to leave the facility after there has been an advisory of inclement weather conditions and/or weather predictions. These include, but are not limited to:
a. Temperature Extremes:
1) For colder temperatures, wind chill readings and predictions will be taken into consideration
2) For warmer temperatures, humidity and air quality readings and predictions will be taken into consideration
b. Inclement weather: This includes weather conditions that pose added risk to my well-being, including, but not limited to: snow, ice, wind, rain, lightning/thunder, sleet and hail.
10. I take full responsibility for notifying the facility if I am not returning the resident back to the facility by the designated time. If I do not return the resident back to the facility by the designated time and have not called, I understand that I will be in violation of the out on pass privileges. This will constitute my wishes to discharge the resident and therefore consider this my consent for discharging the resident against medical advice;
11. I understand that passes will be issued for escorted out on pass between the designated hours, unless special arrangements have been made in advance;
12. I understand that if I do not follow the above conditions, this agreement permitting escorted out on pass and corresponding physician's order allowing my leave of the facility unescorted will be rescinded pending further administrative and interdisciplinary team review.