Failure to Notify Resident Representative of AMA Discharge
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident left the facility Against Medical Advice (AMA). The resident, who had diagnoses including Disorganized Schizophrenia and Psychosis, was admitted with a responsible party listed as an advocacy group. The resident was taking antipsychotic medications and had an active discharge plan for return to the community. On the day of the incident, the resident was found missing by staff, later located in another resident's room, and expressed a strong desire to leave the facility. The DON consulted with the physician, who advised allowing the resident to leave AMA. The resident refused to sign the AMA form and subsequently left the facility. Despite the facility's policy requiring notification of the resident's representative when a resident leaves AMA, the responsible party was not successfully notified. The DON reported making three or four phone calls and leaving a voicemail, but no response was received. The Social Services Director confirmed that the health care proxy should be notified about any incident and is the person designated to sign a resident out AMA. The resident's advocate stated during an interview that they were not notified of the resident's departure and expressed concern for the resident's safety and need for medication. Documentation reviewed included the resident's demographic sheet, admission/discharge/transfer list, MDS, physician's orders, care plan, and progress notes. The facility's policy on AMA discharge clearly outlined the requirement to notify the resident's representative and document the notification in the medical record. However, the lack of successful notification and documentation of the responsible party's awareness of the resident's AMA discharge constituted a failure to meet the regulatory requirement for notification of changes.
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 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. The same monitoring process will be repeated: 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.