Failure to Notify Resident's Representative of Change in Condition During AMA Discharge
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition when the resident, who had a diagnosis of Disorganized Schizophrenia and Psychosis, left the facility Against Medical Advice (AMA). The resident was admitted with a responsible party listed as an advocacy group and was taking antipsychotic medications. Documentation showed that the resident had no cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, and was actively involved in discharge planning for a return to the community. On the day of the incident, the resident insisted on leaving the facility, and the physician advised allowing the resident to leave AMA. The resident refused to sign the AMA form, and the responsible party was not present or notified in person. Interviews and record reviews revealed that the Director of Nursing attempted to contact the responsible party by phone several times and left voicemails, but no response was received. The Social Services Director confirmed that the health care proxy should be notified and is the person authorized to sign a resident out AMA, but this did not occur. Facility policy requires notification and documentation of the resident's representative when a resident leaves AMA, but this was not completed as required. The resident's advocate stated they were not informed of the resident's departure and expressed concern for the resident's safety and need for medication.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 no longer resides in the facility. Resident left AMA 5/5/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review over the last 30 days by the DON/designee to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record to be completed by 7/31/2025. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure the responsible party is notified of a resident's change in condition who leave the facility AMA with documentation in the medical record 7/31/2025. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/designee to conduct ongoing quality monitoring through clinical meeting to ensure the responsible party is notified of a resident's change in condition who leave AMA with documentation in the medical record 2 x weekly x 4 weeks, weekly x 2 weeks then twice monthly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.