Failure to Complete Required Elements for AMA Discharge
Penalty
Summary
The facility failed to ensure all required elements were completed for a resident who was discharged against medical advice (AMA). The resident's care plan did not include discharge planning until three days prior to the AMA discharge, and the only documentation was the resident's wish to return to the community. There was no evidence of comprehensive discharge planning, education on the risks of leaving AMA, or documentation of provider notification. The only education documented was that the facility could not provide medications to take upon discharge. There was also no record of the provider being notified, no recapitulation of the resident's stay, and no documentation of contact with other entities regarding the risks associated with the AMA discharge. A review of the AMA release form showed it was signed by the nurse and the resident, but lacked a second witness signature and only included a brief handwritten note about the resident's departure. Staff interviews confirmed that education and family contact occurred but were not documented. The facility's policy requires informing the resident and family of risks, notifying the physician, and documenting these actions, none of which were fully completed or documented in this case.