Inappropriate Discharge of Resident with Schizophrenia
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of disorganized schizophrenia and colostomy status left the facility against medical advice (AMA) without a safe and appropriate discharge plan. The resident, who was cognitively intact but had a history of delusional thinking and required ongoing antipsychotic medication, expressed a desire to leave and was presented with an AMA form, which he refused to sign. The facility did not obtain a valid address for the resident's next place of residence, nor did they inform the resident's advocate or representative about the AMA discharge. At the time of the survey, the resident's location was unknown. Facility staff failed to ensure that the resident was safely discharged to a location where ongoing clinical care could be provided. The Social Services Director was not involved in the discharge process and was not notified until after the resident had left. The resident's primary care physician and psychiatrist were not promptly informed of the resident's departure, and the facility did not conduct a wellness check or notify law enforcement, as no police or missing person reports were filed. The facility's own policy required notification of the resident's representative and documentation in the medical record, but these steps were not completed. Interviews with facility staff revealed confusion and lack of coordination regarding the resident's whereabouts and the discharge process. The Director of Nursing and Administrator acknowledged that the resident left without providing a destination and that attempts to contact the advocate were limited to leaving voicemails. The Social Services Director confirmed that she was not involved in the process and did not have a discharge location to perform a wellness check. The resident's advocate and medical providers expressed concern about the resident's safety and the lack of communication from the facility.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 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 isft 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; Quailty review over the last 30 days by the DON/designee to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility 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 a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and 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 to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility 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. Current licensed nurses re-educated by the DON/designee on the components of this regulation and to ensure a valid addresses is obtained upon admission/re-admission, to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and 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 to ensure a valid addresses is obtained upon admission/re-admission to ensure residents are safely and appropriately discharged to a safe location where ongoing clinical care can be provided, and the responsible party is notified of a resident's change in condition who leave the facility 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.