Failure to Provide Discharge Instructions in Resident's Preferred Language
Penalty
Summary
The facility failed to provide a resident with discharge instructions in the resident's preferred language of Spanish when the resident left the facility Against Medical Advice (AMA). The resident, who had a history of alcoholic cirrhosis with ascites, protein calorie malnutrition, and alcohol dependence, was sometimes able to understand and be understood by others, with Spanish documented as the preferred language. On the day of the incident, the resident expressed a desire to leave after being placed on a one-on-one sitter following an alleged physical abuse incident with another resident. The resident signed an AMA form, which was witnessed by two RNs, neither of whom could speak or translate Spanish. The review of facility records and interviews confirmed that the AMA form and related discharge instructions were not provided in Spanish, and the resident did not receive information about the risks and benefits of leaving AMA in a language he understood. Facility policies require that residents be informed of their rights and responsibilities and be supported in exercising those rights, including being informed in a manner they can understand. The failure to provide instructions in the resident's primary language resulted in the resident not being fully informed to make an appropriate decision regarding leaving the facility AMA.