**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and records reviews, the facility failed to provide appropriate notice of discharge for a facility-initiated discharge, when the Resident did not initiate a request of discharge for one Resident (#72) out of three closed records. Specifically, the facility failed to provide appropriate notice of discharge to Resident #72 when: -the facility determined that the Resident was acting Against Medical Advice (AMA) by driving his/her personal vehicle to a scheduled eye surgery appointment. -the facility notified the Resident he/she was discharged upon return to the facility from the scheduled eye surgery appointment. -the Resident's personal belongings were packed without his/her participation and he/she was discharged with personal belongings to his/her vehicle, resulting in emotional distress when the Resident expected to return to the facility after the eye surgery appointment. Findings include: Review of the facility policy titled Transfer or Discharge Resident-Initiated, revised October 2022, indicated the following: -Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. -Discharge refers to the movement of a resident from one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. -Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home .) a. Therapeutic Leave is a type of resident-initiated transfer. However if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge. b. A resident's lack of objection to a facility-initiated transfer or discharge is not considered resident-initiated. c. A resident verbal or written notice of intent to leave against medical advice is considered a resident-initiated discharge. -Documentation: 1. For resident-initiated discharges, the medical record contains: a. Documentation of evidence the resident's or resident representative's verbal or written notice of intent to leave the facility; b. a discharge care plan; and c. documented discussions with the resident, or if appropriate, his/her representative containing details of discharge planning and arrangements for post-discharge care. 2. The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident initiated. Resident #72 was admitted to the facility in October 2024 with diagnoses including Peripheral Vascular Disease (PVD), Chronic Kidney Disease (CKD) Stage 4, Depression, and Anxiety. Review of a recent Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #72: -was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) score of 15 out of a total possible 15. Review of the Discharge MDS assessment dated [DATE], indicated Resident #72: -BIMS assessment was not conducted. -was assessed as Independent for making decisions regarding tasks of daily life and there was no acute mental status change. -MDS was a discharge assessment with return not anticipated. -Discharge was unplanned. -Discharge location was to home/community. Review of Resident #72's Comprehensive Plan of Care for Discharge Potential, initiated 10/9/24, indicated the following goal and interventions: >I plan to discharge to community alone, community with family, ALF (Assisted Living Facility), LTC (Long term care) placement, other - Undecided at current time. Pending outcome of therapy sessions, clinical medical stability progress reviewed weekly, initiated 11/29/24. >Encourage patient and family to be involved in planning of care and discharge planning, initiated 10/9/24. >Notify MD (Medical Doctor) of discharge plans, ensure all required discharge documentation is complete including Orders, and prescriptions are available at time of discharge, initiated 10/9/24. >Nursing, Care Navigator (Social Work), Clinical Nurse Navigator, and therapy shall discuss progress and discharge plan weekly and as needed, initiated 10/9/24. Further review of the Comprehensive Plan of Care for Discharge Potential failed to indicate any interventions relative to driving or coordination with any specific community support services. Review of Resident #72's Physician's orders, discontinued 3/13/25, indicated the following: -May go out for appointments, initiated 10/6/24, with no end date. -discharged AMA (against medical advice) with personal belongings, ordered 3/7/25, with no end date. Review of the Nurse Practitioner (NP) Encounter Note dated 3/6/25, indicated: -[Resident] reports he/she has [Lasik eye] surgery tomorrow and a friend will be bringing him/her. Further review of Resident #72's NP Encounter Note dated 3/6/25, indicated an addendum on 3/8/25 at 7:03 A.M. with the following: -[Resident] left the facility today to go to Lasik appointment. -He/she was not cleared to drive but ended up taking his/her car him/herself anyways. -Due to this he/she was advised to go to hospital for re-evaluation and not able to return. Review of the Leaving Against Medical Advice (AMA) Form, dated 3/7/25, indicated: -I, [Resident #72], am leaving against the advice of my Physician and the facility. -Documented as refused in Resident signature section. -Signed by DON (Director of Nursing) and Administrator as facility representative and witness, respectively. -Comments section on the Leaving Against Medical Advice (AMA) Form was blank. Review of Resident #72's Nursing Progress Note dated 3/7/25 at 15:17 (3:17 P.M.) indicated: -[Resident] left the facility prior to being formally discharged and was seen driving their personal vehicle to a scheduled appointment. -The [Resident] chose to leave the facility against medical advice (AMA). Further review of the Nursing Progress Note dated 3/7/25, failed to indicate that any notice of discharge was provided to Resident #72 at the time of discharge or that the Resident consented to an AMA discharge. Review of Resident #72's Social Service Progress Note dated 3/7/25 at 18:02 (6:02 P.M.) indicated: -Social Worker (SW) #2 was made aware during morning meeting that [Resident] was driving to an appointment by him/herself and had just left the facility. -Social Worker informed management that [Resident] was not given the approval to drive by the Medical Doctor. -[Resident] was informed that if he/she went out and drove . it would be considered him/her leaving against medical advice. -When [Resident] returned to the building DON and Administrator met with [Resident] and helped him/her put his/her belongings into the vehicle. -[Resident] was discharged AMA and Elder Protective [report] will be submitted. Further review of the Social Service Progress Note dated 3/7/25, failed to indicate that any notice of discharge was provided to the Resident or that the Resident consented to an AMA discharge. During an interview on 4/3/25 at 3:01 P.M., with surveyor #1, the Director of Nursing (DON), and the Administrator, the DON said that on 3/7/25, the Resident had planned eye surgery that day and the facility had booked transportation. The DON further said that the transportation company had arrived that day to pick up Resident #72 as observed by the Receptionist and Nurse #1, and Resident #72 turned the transportation away. The DON said that around noontime, Resident #72 and Resident Representative (RR) #1 arrived back at the facility and the DON said she witnessed the Resident and RR #1 arrive in separate vehicles and the Resident was wearing specialty glasses at the time. The DON said she spoke with Resident #72 privately and said to the Resident that he/she had left the facility and driven his/her vehicle which was considered against medical advice. The DON said she provided Resident #72 with information about going to the hospital. The DON said that Resident was out of the facility (away) on 3/7/25 from around 8:00 A.M. to noon. The DON said she left phone messages for the Resident and RR #2 informing them of the concern of leaving against medical advice. During an interview on 4/3/25 at 3:03 P.M., with surveyor #2 and Social Worker (SW) #1, SW #1 said that Resident #72 had been working with Social Worker (SW) #2 and that SW #2 was no longer employed at the facility. SW #1 said that Resident #72 had his/her personal vehicle on admission to the facility, was homeless, and had nowhere to store the vehicle. SW #1 said the Resident told staff that he/she was going to a medical appointment and he/she was told it was not in the Resident's best interest to drive due to the nature of the appointment. SW #1 said that she was not in the facility when the Resident left on 3/7/25, but the facility had transportation arranged for the Resident's appointment and SW #1 said she believed the Resident cancelled the transportation. SW #1 said the facility's process for Against Medical Advice (AMA) discharge is to educate the Resident regarding the risks of AMA, attempt to get them a Visiting Nurse Agency, and file a protective services report. SW #1 said the facility does not provide a notice of transfer or discharge to residents that leave AMA but the Ombudsman is notified of AMA discharges. During a telephone interview on 4/4/25 at 8:33 A.M., the Resident was contacted by surveyor #2 as he/she is no longer residing at this facility. Resident #72 said that he/she was admitted to the facility after hospitalization and was a Resident at the facility from October 2024. Resident #72 said he/she had Lasik eye surgery planned on 2/21/25, and waited for transportation which had been arranged by the facility for 2/21/25 but transportation did not show. Resident #72 said he/she was frustrated with the transportation process, had re-scheduled the eye surgery him/herself, and indicated to staff that he/she wanted to make his/her own arrangements for transportation to the new appointment. Resident #72 said he/she communicated the new eye surgery appointment to RR #2 who planned to drive him/her to the appointment. Resident #72 said on the morning of the re-scheduled appointment (3/7/25), he/she notified Nurse #1 of the eye surgery appointment, RR #2 arrived to the facility and drove the Resident in his/her own vehicle to the appointment. Resident #72 further said that RR #2 dropped him/her off at the appointment, RR #2 then returned the Resident's vehicle to the facility, and RR #2 left the facility in their own vehicle. Resident #72 said he/she made arrangements with RR #1 to pick him/her up after the eye surgery appointment and RR #1 was the person who drove him/her back to the facility in RR#1's vehicle. Resident #72 said when he/she and RR #1 returned to the facility and went to his/her room, there was none of his/her personal belongings in the room at that time. Resident #72 said after that he/she was approached by a Staff Member, whom he/she thought was the Administrator, who told him/her that he/she was outta here, I saw you drive to the appointment. Resident #72 said that he/she was not provided with any AMA paperwork and/or medications at that time. Resident #72 said he/she tried to explain to the Staff Member that RR #2 drove the Resident's vehicle to the appointment that morning and the Staff Member did not see him/her switch cars with RR #2. Resident #72 said he/she knew that he/she was not supposed to drive to the appointment as it was planned eye surgery. Resident #72 said that the Maintenance Director placed big green bags of his/her belongings in the back of the Resident's and RR #1's vehicle. Resident #72 said that he/she felt terrible with a total emptiness inside and that he/she thought what did I do wrong? Resident #72 further said they went through all of my personal belongings without me being there which I felt was the wrong way to do it. Resident #72 said after he/she spoke with the Staff Member and his/her belongings were loaded in his/her vehicle, the Resident and RR #1 sat in his/her vehicle for about 30 minutes to see if anyone would ask them to leave the property. Resident #72 said I was not sure what I would do. Resident #72 said that he/she then called RR #2 to discuss his/her options and he/she decided to go to the hospital from the facility. Resident #72 said he/she was admitted to a local area hospital the same day he/she left the facility and that the local area hospital was unable to place him/her in another local nursing home after about a week. During a telephone interview on 4/4/25 at 9:16 A.M., with surveyor #2, Resident Representative (RR) #1 said that he/she picked up the Resident around noon from the eye surgery appointment and returned to the facility with the Resident in RR #1's vehicle. RR #1 said when he/she and the Resident entered the facility and went to the Resident's room, none of Resident #72's personal belongings were in the room. RR #1 said that Resident # 72 met with one of the facility staff privately and the Resident told RR #1 They kicked me out, I have to leave. RR#1 said that he/she checked the Resident's room again to locate any belongings left behind, and found the Resident's car keys in the nightstand drawer. RR #1 said that RR #2 had driven Resident #72 to the eye surgery appointment, and drove his/her vehicle back from the appointment and dropped the car keys off to the facility. RR #1 further said the Resident was very upset that he/she had no place to go and just had an operation. RR #1 said the whole thing was a traumatic experience for me and Resident #72. They had all of his/her stuff packed already and then loaded it into the Resident and my cars. During an interview on 4/4/25 at 10:34 A.M., the Maintenance Director (MD) said that the Resident had their vehicle on the property since his/her admission to the facility. The MD said that he had been out of the facility on the morning of 3/7/25 and returned to the facility around midday and observed several large full travel bags that the facility used for residents that were discharging on a flatbed cart. The MD said the Administrator told him the travel bags were Resident #72's items and the MD was instructed by the Administrator to bring the bags outside to the Resident. The MD said that he brought the bags out to the Resident's car and put one bag in the Resident's friend's vehicle as well. During an interview on 4/4/25 at 10:56 A.M., with surveyor #2, the DON, Nurse #1, and CNA #2, Nurse #1 said that she and CNA #2 packed up the Resident's belongings as instructed by the DON. Nurse #1 said that she attempted to call the Resident and RR #2 without success and left voicemails indicating the Resident had left the facility against medical advice, that his/her belongings were packed by staff, and that the belongings would be given to him/her in the lobby when he/she returned. Nurse #1 further said the Resident returned to the facility around noon accompanied by a friend, came back up to the floor and back to his/her room. The DON said that she was the Staff Member who spoke with the Resident on 3/7/25, but she did not document the conversation when he/she provided the Resident with AMA paperwork. The DON said that she provided education to the Resident that he/she could go to two of [local area hospital] emergency rooms and the Resident left in their own vehicle and was ambulating with a cane at the time. The DON said that a notice of discharge was not provided to the Resident as Resident #72 had left against medical advice. During an interview on 4/4/25 at 11:45 A.M., SW #1 said that there was no documentation of any discharge paperwork provided to Resident #72. During a telephone interview on 4/4/25 at 11:46 A.M., Resident Representative (RR) #2 said that he/she arrived to the facility on 3/7/25 around 9:20 A.M., the Resident had his/her vehicle started and running when he/she arrived, and RR #2 drove Resident #72 to the eye surgery appointment in the Resident's vehicle. RR #2 said that he/she returned to the facility around mid-morning after dropping off the Resident at the eye surgery appointment. RR#2 said that he/she saw CNA #3 in the lobby when he/she returned and asked CNA #3 if the CNA would bring the Resident's car keys back to his/her room. RR #2 said CNA #3 took the car keys and RR #2 left the facility. During a telephone interview on 4/4/25 at 12:17 P.M., CNA #3 said on 3/7/25 around 10:30 A.M., she was returning from her morning break and was approached in the facility lobby by RR #2. CNA #3 said that she recognized RR #2 as Resident #72's relative, that they knew each other, and RR #2 handed CNA #3 a set of keys and asked CNA #3 to put them in Resident #72's nightstand drawer. CNA #3 said that she put the keys in the Resident's nightstand drawer as requested and returned to her scheduled shift assignment. Please Refer to F623