Failure to Provide Discharge Summaries and Medication Reconciliation for Residents Leaving AMA
Penalty
Summary
The facility failed to provide appropriate discharge instructions, including a discharge summary or recapitulation of stay, for three residents who left the facility against medical advice (AMA). For each of these residents, documentation was incomplete or missing regarding their medical status, medication reconciliation, and other essential discharge information at the time of their departure. The facility's policy required that AMA discharges be processed in accordance with the resident's or representative's request for a safe and appropriate discharge, with applicable documentation completed, but this was not followed. One resident with diagnoses including type II diabetes, protein-calorie malnutrition, and dysphagia left the facility AMA without documentation of a discharge summary or medication reconciliation. The discharge plan documentation for this resident was incomplete, lacking information on home/community status, follow-up care, skin condition, diet, infections, assistance needs, therapy services, and medication changes. Another resident with type II diabetes and atrial fibrillation also left AMA, and similarly, there was no documentation of attempts to provide a discharge summary or medication reconciliation. The discharge plan documentation for this resident was also incomplete in several key areas. A third resident, with a history of falls and a healing fracture, left the facility AMA to a shelter, and there was no evidence of a completed discharge summary or discussion of medication reconciliation prior to discharge. Interviews with staff revealed a lack of awareness regarding the requirement to provide discharge summaries for residents leaving AMA, and record reviews confirmed the absence of completed discharge documentation for all three residents involved.