Failure to Notify Physician of Residents’ AMA Discharges
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring prompt notification of the attending physician or provider when a resident leaves against medical advice (AMA). For one resident admitted with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed moderately impaired cognition on the most recent MDS, with independence in eating, partial assistance with toileting, substantial assistance with bathing, and setup for personal hygiene. On the day of discharge, the resident’s BIMS score was 13, indicating cognitively intact status, and the resident signed an Unauthorized Discharge Release of Responsibility form to leave AMA after the facility documented discussion of the risks and attempts to have the resident remain. However, the Medical Director/provider was not notified of this AMA discharge, and the Medical Director later confirmed he had never been informed. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential HTN, had an MDS indicating independence with eating, dependence on staff for toileting and bathing, and partial assistance with personal hygiene. This resident was discharged AMA by the resident’s Guardian, as documented in a progress note. Review of the medical record revealed no documentation that the Medical Director/provider was notified when the resident left AMA, and the Regional Clinical Director confirmed that the provider was not notified at that time. The facility’s written policy titled “Discharging a Resident Without a Physician’s Approval” states that when a resident or representative requests discharge earlier than outlined in the care plan and without physician approval (AMA), the attending physician or provider is to be promptly notified. The failure to notify the physician/provider for both AMA discharges constituted non-compliance and was cited under Complaint Number 2699059.
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