Failure to Document Against Medical Advice (AMA) Discharge
Penalty
Summary
The facility failed to ensure proper documentation in the medical record for a resident who was discharged against medical advice (AMA). Specifically, a resident with chronic heart failure, muscle weakness, and chronic kidney disease was admitted and later left the facility with his wife without following the established sign-out procedures. The nurse was not notified prior to the resident's departure, and the resident's wife only signed the resident out in the front desk book after being prompted by a nurse aide. The medical director and DON were notified of the situation, but there was no documentation in the resident's medical record regarding the AMA discharge. Interviews confirmed that the resident's wife took him home with no intention of returning, citing dissatisfaction with the care provided. The business office manager verified that the medical record lacked any documentation of the AMA discharge, and a review of facility policy indicated that such documentation should have been entered by nursing and social services staff. This deficiency affected one of three residents reviewed for discharges.