Failure to Ensure Accurate Discharge Documentation and Resident Preparation
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate discharge procedures for a resident who was assessed as cognitively intact and capable of making decisions. The resident, who had diagnoses including end stage renal disease, diabetes, dementia, and dependence on renal dialysis, was admitted with orders for regular dialysis and a limited out-on-pass privilege. On the day of the incident, the resident was observed leaving for a scheduled dialysis appointment but did not arrive at the dialysis center. The facility was notified by the dialysis center that the resident was missing, and subsequent attempts to contact the resident were unsuccessful. The police were notified later that evening, and a missing person report was filed. Despite the resident's absence, the facility documented the discharge as 'against medical advice' (AMA) without evidence of a physician discharge order, care plan, interdisciplinary team documentation, or any indication that the resident was informed of or participated in a planned discharge. The facility's policy required detailed documentation and communication for transfers or discharges, including preparation of a post-discharge plan and notification of the resident and their representative. None of these steps were documented in the resident's medical record. Interviews with facility staff and the physician revealed that the decision to discharge AMA was based on the resident exceeding the out-on-pass time limit, but there was no formal documentation of behavioral concerns, care plan interventions, or interdisciplinary review regarding the resident's history of leaving without notice. The resident was later found by a security guard at a local hotel and returned to the facility, after which the facility arranged for transfer to an acute care hospital for missed dialysis treatments. The resident was subsequently readmitted to the facility. Throughout the incident, there was a lack of documentation regarding the basis for discharge, communication with the resident or their emergency contacts, and adherence to facility policies and procedures for safe and appropriate discharge planning.