Incomplete Documentation for Discharge Against Medical Advice
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate when the resident discharged against medical advice. A resident with diagnoses including acute osteomyelitis, acquired absence of right leg below knee, and diabetes left the facility with his sister against medical advice after expressing dissatisfaction with his care since admission. Although the resident had been informed of the risks associated with leaving against medical advice, there was no progress note in the clinical record documenting the details of the discharge. Interviews with the resident and the Director of Nursing (DON) confirmed that the resident and his sister notified staff as they were leaving, and the DON acknowledged that a nurse should have entered a progress note at the time of discharge. Review of the facility's policy indicated that documentation should include staff attempts to provide other options and information about the risks of leaving, but this documentation was missing from the resident's record.