Failure to Supervise and Complete Discharge Procedures for Resident Who Left Facility
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and appropriate discharge procedures, resulting in the resident leaving the facility without staff knowledge or proper documentation. The resident, admitted with diagnoses including aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis, had intact cognition as indicated by a recent mental status evaluation. On the day of the incident, the resident expressed a desire to leave and was medically cleared for discharge by a nurse practitioner, but no formal discharge order, signed AMA paperwork, or discharge summary was completed. Throughout the day, multiple staff members noted the resident's intention to leave and observed behaviors such as packing belongings and arranging a ride with a friend. Despite these observations, staff did not ensure the resident remained in the facility until proper discharge procedures were completed. The resident was not present for scheduled rounds or meetings, and staff assumed at various points that the resident was either at an appointment or would wait for discharge planning. It was not until a late afternoon meeting that staff realized the resident was missing, prompting an Elopement Code and a search of the facility. After failing to locate the resident, staff assumed the resident had left against medical advice but did not notify law enforcement as required by facility policy. There was no evidence of a completed discharge process, medication reconciliation, or referral to home care services. Interviews with staff and the resident confirmed that the resident left the facility with a friend, did not receive necessary paperwork or medications, and that the facility did not follow its own elopement and discharge protocols.