Failure to Ensure Safe Discharge for Resident Leaving Against Medical Advice
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who left against medical advice (AMA). The resident, who had a sacrum fracture and a Stage 4 pressure injury, left the facility with family members to a location three hours away, rather than returning to her home in a nearby town as documented. There was no physician's order for the discharge, and the medical director was not notified of the resident's departure. The discharge summary inaccurately stated the resident's destination, and the facility did not complete or offer an AMA form to the resident or her family. There was no documentation of any discussion with the resident or her family regarding the risks and implications of leaving the facility AMA or the suitability of the discharge location. The facility also failed to document any discussion of alternative, more appropriate discharge options, nor did they record that such options were offered and refused. Interviews with family members confirmed that no alternatives or consequences were explained to them prior to the resident's departure. Additionally, the facility did not conduct an investigation or determine if a referral to Adult Protective Services (APS) was necessary, as required by their policy when a resident is discharged to a potentially unsafe setting. Staff interviews confirmed that these steps were not taken, and the director of nursing acknowledged that the required notifications and documentation were not completed. The resident was admitted to an acute care hospital within two days of leaving the facility with an infection.