Failure to Follow AMA Discharge Policy and Documentation
Penalty
Summary
The facility failed to follow its policy and procedure for Discharge Against Medical Advice (AMA) for one resident. According to the discharge summary, the resident was discharged AMA, but there was no documentation of an AMA form in the resident's chart, no evidence of attempts to discuss the discharge with the resident, and no documentation confirming the resident's safety upon leaving. Interviews with staff revealed that the resident left the facility without informing staff of her intention to leave or dissatisfaction with care, and staff only became aware of her absence after she had already exited the building. The facility's policy required staff to attempt to encourage the resident to remain for continued treatment and to have the resident review and sign an AMA form upon discharge, neither of which occurred in this case.