Failure to Provide Safe and Appropriate Discharge Planning for Resident Discharged AMA
Penalty
Summary
The facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for a resident who was discharged against medical advice (AMA) after not returning from an authorized pass. The facility did not follow its own policy regarding AMA discharges, as the policy did not support automatic discharge for failing to return from a pass, and staff admitted that the resident did not initiate a request to leave or intend to be discharged. The resident was discharged without timely written notice, and the required discharge notice was not provided in advance or as soon as possible. Additionally, the resident's care plan did not include a discharge plan addressing needs such as medication management, home health referral, or durable medical equipment (DME), and there was no interdisciplinary care team (IDT) meeting to discuss or plan for the resident's discharge needs or placement. The resident had multiple complex medical diagnoses, including polyneuropathy, acute on chronic systolic heart failure, COPD, obstructive sleep apnea, hypertension, and a pacemaker, and required assistance with personal care and supervision for transfers. Despite these needs, the facility did not identify the location of discharge, complete a referral to an appropriate community agency, or provide a discharge summary that included the assistance needed for the resident to adjust to a new living environment. The post-discharge plan of care did not address the resident's limitations or ability to care for himself, and the resident's whereabouts were unknown after discharge. Interviews with facility staff confirmed that the resident was considered discharged AMA solely due to exceeding the allowed hours for being out on pass, despite the facility's policy stating that extended therapeutic leave is not grounds for discharge. The resident was not provided with medications at the time of discharge, only a medication list, and was not given the opportunity to appeal the discharge decision. The facility's own policies required an IDT-developed discharge plan and summary, which were not completed. The lack of proper discharge planning and communication endangered the health and safety of the resident, who was unexpectedly discharged without appropriate preparation, placement, or follow-up care.