Failure to Follow AMA Discharge Policy and Documentation Requirements
Penalty
Summary
The facility failed to implement its policy and procedure regarding the discharge of a resident without physician approval for one resident. The resident, who had multiple diagnoses including diabetes mellitus, hypertension, muscle weakness, abnormal gait, and a local skin infection, left the facility against medical advice (AMA) after communicating his intention to staff via text and phone. Documentation shows that the resident was advised of the risks and benefits of leaving AMA and that the physician, DON, Administrator, and SSD were notified of his absence. However, there was no evidence that the resident signed the required AMA acknowledgement form, nor was there documentation that the resident refused to sign the form, as required by facility policy. Additionally, there was no documentation that licensed nurses notified the physician when the resident returned to the facility or when he was officially discharged AMA. Interviews with staff, including an LVN and the DON, confirmed that the established process for AMA discharges was not followed. The DON stated that the process should have included physician notification, discussion of risks and benefits with the resident, and obtaining the resident's signature on the AMA form, or documenting refusal to sign. The facility's policy requires that if a resident insists on discharge without physician approval, a release of responsibility form must be signed or refusal documented and witnessed by two staff members. These steps were not completed in this case, resulting in a failure to follow the facility's discharge policy.