Failure to Ensure Safe and Orderly AMA Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who left against medical advice (AMA). The resident, who had intact cognition and required minimal to limited assistance with activities of daily living, had multiple diagnoses including type II diabetes mellitus, major depressive disorder, hypertension, osteoarthritis, hypothyroidism, and hyperlipidemia. Although the resident had previously planned to discharge to an assisted living facility, she ultimately left the facility with her daughter, refusing to re-enter the building. The facility provided an AMA form for the resident to sign in a vehicle, but did not complete a comprehensive discharge plan or adequately document efforts to educate the resident about the risks of leaving AMA. There was no documentation of a recapitulation of stay or a discharge summary in the resident's electronic health record at the time of discharge. The discharge summary was only entered as a late entry after being requested by a surveyor. Interviews with facility staff confirmed that the usual process of providing a discharge summary, including information on medications, recent labs, and follow-up appointments, was not followed in this case. The facility also did not provide documentation of efforts to educate the resident about appeal rights or bed-hold policies at the time of the AMA discharge.