Failure to Ensure Safe and Informed Discharge for High-Risk Resident
Penalty
Summary
A resident with diagnoses including schizophrenia, major depressive disorder, and diabetes mellitus was discharged from the facility without their knowledge, request, or consent, and against medical advice. The resident had a documented history of elopement risk, with assessments indicating a significant actual risk for wandering or leaving the facility. The care plan and risk assessments reflected these concerns, and physician orders permitted the resident to leave the facility only under specific conditions, such as being out on pass for a limited time. On the day in question, the resident left the facility after stating an intention to go to the post office, but did not complete the required sign-out process, and the log was left incomplete. Staff interviews revealed that the resident was not properly signed out, and that staff were aware of the resident's behavioral challenges, including agitation and aggression. Following the resident's departure, the facility was unable to confirm the resident's whereabouts or safety, and attempts to contact the resident's emergency contact were unsuccessful. The facility subsequently classified the resident as having left against medical advice and processed a discharge without confirmation of the resident's location or well-being. Facility policy required all residents leaving the facility to be signed out, a step that was not completed in this case. The deficiency was identified due to the facility's failure to ensure a safe and informed discharge process, particularly for a resident with known elopement risk and behavioral health concerns.