Failure to Document and Notify Physician During AMA Discharge
Penalty
Summary
The facility failed to provide and document adequate discharge preparation and notification for a resident who left the facility against medical advice (AMA). The resident, who had diagnoses including anxiety, a patella fracture, and hypertension, was admitted following a fall and subsequently left the facility with her representative due to dissatisfaction with facility conditions. The discharge care plan indicated a desire to return home or transfer to another facility, but there was no evidence in the electronic medical record (EMR) that the physician was notified of the resident's or representative's request to discharge, nor was there documentation explaining why the physician could not be reached until the following day. Additionally, there was no documentation that the physician was notified after the resident left AMA. The EMR also lacked evidence that staff attempted to discuss the resident's concerns or reasons for leaving, or that alternative discharge plans were explored. An AMA discharge form was present but was not signed by the representative. Staff interviews confirmed the absence of required documentation and indicated that the expected process for AMA discharges, including physician notification and progress notes, was not followed in this case.