Failure to Follow Discharge and AMA Policies for Resident Leaving Facility
Penalty
Summary
The facility failed to follow its discharge and Against Medical Advice (AMA) policies when discharging a resident who left the facility without proper documentation or preparation. The resident, who had multiple medical diagnoses including epilepsy, dysphagia, anxiety disorder, and depression, was cognitively intact but required staff supervision or assistance for all activities of daily living. Despite the resident expressing a desire to leave and being denied a community pass due to not following curfew rules, the facility did not ensure that the discharge process was properly documented or that the resident was adequately prepared for a safe transition. There was no evidence that the resident or their responsible party was educated on the risks of leaving AMA, nor was there documentation that the attending physician was notified and given the opportunity to educate the resident as required by policy. The facility was unable to provide a signed AMA form or documentation that the form was presented and refused, as outlined in their procedures. Additionally, the resident left without his medications or personal belongings, which were instead packed and sent to storage. Attempts to contact the resident after discharge were unsuccessful, and the facility did not know the resident's current location or condition. Interviews with staff confirmed that the required steps for AMA discharge, including documentation of education, physician notification, and proper completion of forms, were not followed. The lack of adherence to policy resulted in the resident being discharged to an unknown location without assurance of safety or continuity of care.