Failure to Document and Ensure Safe AMA Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including a clavicle fracture, abnormal gait, morbid obesity, and malaise, was discharged against medical advice (AMA) without proper documentation or investigation by facility staff. The resident was responsible for her own care and had a daughter, but the medical record lacked a discharge summary and a physician's discharge order. There was no evidence in the record that the resident was safely discharged, and staff could not explain why the resident did not complete her prescribed six weeks of therapy. The Rehabilitation Director, Social Worker, Business Office Manager, and Unit Manager all confirmed the absence of required documentation and could not provide details regarding the circumstances of the resident's departure or the provision of necessary discharge information. Further review revealed that the Social Worker was unable to locate an AMA form or evidence that the physician was notified of the resident's AMA discharge. There was also no documentation that the resident received a medication list or instructions to follow up with her provider. The Business Office Manager confirmed that the resident was not informed about potential Medicare non-payment for leaving AMA, and the Unit Manager could not identify the nurse responsible at the time of discharge. Overall, the facility failed to ensure a safe and documented discharge process for the resident who left AMA, as required.