**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of an Against Medical Advice (AMA) form, hospital record review, review of the policy and procedure titled Discharging a Resident without a Physician's Approval policy and interviews with facility staff, Physician #399, a Patriot Emergency Medical Service representative, and an Amedysis Home Health representative, the facility failed to ensure a safe and orderly discharge for Resident #94, who had diagnoses including respiratory failure, protein-calorie malnutrition, osteomyelitis, cerebral infarction, sepsis, COVID-19 and dementia when the resident was discharged to an unsafe home environment on [DATE]. This resulted in Immediate Jeopardy on [DATE] at approximately 1:32 P.M., after the facility originally initiated and then allowed Resident #94 to discharge to a documented unsafe environment indicating the discharge was Against Medical Advice (AMA). Resident #94 had multiple medical conditions that required continual care including multiple skin tears, a Stage IV (full thickness skin loss extending through the fascia) pressure area to her coccyx, a Stage II (partial thickness skin loss) pressure area to her right heel, and antibiotic therapy for treatment of diagnosed cellulitis to her right upper extremity. In addition, Resident #94 was dependent on staff with a two-person, physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene and was dependent on staff with a one-person physical assist for eating and locomotion. The risk for actual harm, injury or death occurred on [DATE] as the facility lacked evidence to support a comprehensive and individualized discharge plan to meet the resident's total nursing and medical needs (i.e. antibiotic therapy, insulin therapy, wound care) at home or evidence the resident was requesting an AMA discharge. Resident #94 had no guardian or power of attorney (POA). The physician was unaware of the discharge at the time it occurred. The facility provided no discharge teaching or preparation for the discharge to the resident or family prior to the resident leaving. Resident #94 expired on [DATE] according to her obituary (published [DATE]). This affected one resident (#94) of three residents reviewed for transfer/discharge. The facility census was 92. On [DATE] at 4:50 P.M. the Administrator, the Director of Nursing (DON), Clinical Nurse Consultant (CNC) #999, and [NAME] President of Clinical Services #998 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide a safe and orderly discharge to home for Resident #94, who was picked up from the facility by medical transport arranged by family members. There was no evidence to support the resident's medical conditions, treatments, or upcoming appointments including any necessary provisions of care were coordinated to ensure the resident's total care needs were met after discharge. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • An AD-Hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted on [DATE]. Members at the meeting included the Administrator (CEO), Director of Nursing (DON), Regional Nurse Consultant, Assistant Director of Nursing, Medical Director via phone, Dietary Manager, Social Service Assistant, Medical Records, MDS Coordinator, Human Resources, Business Office Manager, Assistant Business Office Manager, Admissions Coordinator, Social Services Assistant, Staffing Coordinator, Assistant Dietary Director, Therapy Program Manager, and House Keeping Supervisor. The meeting was held to discuss and review abatement actions regarding the identified concern. • On [DATE] the medical records of residents who discharged in the past year were reviewed to identify other residents who had been discharged against medical advice. This audit was completed by the Regional Nurse Consultant with no concerns identified. • On [DATE] a new process, Discharge Against Medical Advice was developed and implemented through collaboration between the Administrator, DON, and Clinical Nurse Consultant to guide staff through a discharge Against Medical Advice. • On [DATE] a new policy was implemented for Discharges Against Medical Advice. The policy includes: o Requirement to notify attending physician of a request by a resident or his/her representative, for discharge. o If the physician determines that the discharge is medically contraindicated, their determination will be discussed with the resident and/or representative. o If discharge is still desired after discussion, reasons for request, risks of leaving and possible alternatives will be discussed. o If discharge is still chosen, then a Release from Responsibility for Discharge Against Medical Advice form will be completed. o Document circumstances and actions taken in the clinical record. • On [DATE] education regarding this policy and use of the accompanying form was initiated on with Licensed Nurses and provided by the Regional Nurse Consultant. Training is being continued with each oncoming shift prior to duty and provided by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or a Clinical Nurse Consultant. No licensed nurse will be permitted to work without training after [DATE]. On [DATE] there were 6 licensed nurses educated with completion of post-test, including 3 agency nurses. On [DATE], all remaining nurses, 14 facility nurses and 3 agency nurses, were educated with post testing completed with the exception of 2 licensed nurses that are currently on medical leave. They will be provided education prior to returning to active duty. All education on [DATE] was provided prior to the start of the nurse's shift. Education material will be added to the orientation process for licensed nurses. • A new Discharge Checklist related to Safe Discharge was developed and implemented [DATE] through collaboration between the Administrator, DON, and CNC to guide nurses in completing all tasks associated with a safe discharge. The checklist includes: o Pre-Discharge tasks including o Obtain MD order for discharge. o Inform resident and representative of discharge. o Notify Social Service Director and Dietary Manager of order for discharge. o Obtain orders for home care. o Arrange for home care as ordered. o Schedule follow-up appointments o Notify pharmacy of upcoming discharge o Complete discharge instruction form o Initiate Discharge Summary form. o At Discharge tasks include: o Orders called in or written prescriptions / med list provided (if medications sent home) o Review Discharge instructions with Resident / Resident Representative o Complete Skin assessment and record findings o Obtain Vital Signs and record. o Discontinue IV's if indicated. o Remove wanderguards, Alarms or Safety equipment not accompanying resident at discharge. o Complete Personal Belongings Inventory and obtain signature. o Remove name band if used. o Assist resident to vehicle, if not transported via ambulance o Document in progress note condition at discharge, time left, how transported, who accompanied, instructions provided and any other pertinent discharge information. o Post Discharge Tasks: o Secure any non-electronic resident records, if any, for Medical Records to collect o Place any medications not sent with resident in designated location for return. o Narcotics to be removed from cart by designated individuals to be secured and destroyed in accordance with state guidance. o Pharmacy, Dietary, housekeeping to be notified of discharge o Equipment removed from room. o Name removed from door. o Discharge (D/C) Summary completed. • On [DATE] education regarding this form was initiated on with Licensed Nurses and provided by the Regional Nurse Consultant. Training is being continued with each oncoming shift prior to duty and provided by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, or a Clinical Nurse Consultant. No licensed nurse will be permitted to work without training after [DATE]. On [DATE] there were 6 licensed nurses educated with completion of post-test, including 3 agency nurses. On [DATE], all remaining nurses, 14 facility nurses and 3 agency nurses, were educated with post testing completed except for 2 licensed nurses that are currently on medical leave. They will be provided education prior to returning to active duty. All education on [DATE] was provided prior to the start of the nurse's shift. Education material will be added to the orientation process for licensed nurses. • A second QAPI meeting was held on [DATE] which included the Administrator (CEO), Director of Nursing, Regional Nurse Consultant, Assistant Director of Nursing, Dietary Manager, Social Service Assistant, Medical Records, MDS Coordinator, Human Resources, Business Office Manager, Assistant Business Office Manager, Admissions Coordinator, Social Services Assistant, Staffing Coordinator, Assistant Dietary Director, Therapy Program Manager, and House Keeping Supervisor, to discuss and review new processes put into place to prevent recurrence of alleged deficient practice. Medical Director participation was conducted via phone following the meeting with approval given for the plan and additional processes • On [DATE] the facility conducted a root cause analysis and determined the Social Service Director did not follow established standards of practice. • On [DATE] the Regional Nurse Consultant reviewed the medical records of all current residents who admitted for short term stays for information suggesting that the planned discharge location/conditions may be unsafe with no concerns identified. • On [DATE] a form was developed to review with resident contemplating a discharge Against Medical Advice requiring review by the resident and or resident representative, acknowledging: o The risks of discharge o The benefits of remaining in the facility o Availability of other Health Care Providers o Release of responsibility for adverse effects resulting from the discharge; including the physician, the facility and its agents or employees • The AMA Discharge Information Sheet includes: o Date of Discharge o Destination o Attending physician and phone number o Pharmacy to be used and phone number. o Discharge Medication list to include times, instructions and reason for use o Treatments being provided. o Assistive Devices being used. o Resident education provided o Community Agencies needed and contact numbers (if applicable) o Additional instructions • The form was to be signed by the resident or Resident Representative, acknowledging review of information, and understanding. The form was to be signed by the nurse reviewing the information with the resident or Resident Representative. If the resident or resident representative refused to sign the form, after it had been reviewed, it should be noted that the information was provided and reviewed by witnesses. • On [DATE] education was provided to the Social Service Director by the Administrator including expectations in the event information is conveyed regarding the appropriateness/safety of the discharge location. Expectations to include immediately communicating concerns to Administrator, any concerns with discharge that may be unsafe so that appropriate investigation and discharge planning can be conducted. • Pre-discharge and At-Discharge Sections of the checklist will be reviewed by the nurse on duty to verify that all tasks have been completed prior to discharge. • Monitoring of effectiveness of the new measures is achieved by initial completion of post-tests following education to assure comprehension of training, for all licensed nurses who were trained. Following initial education, retesting of 10% of the nurses weekly will be completed x 6 weeks. Testing will be completed by Unit Directors, Staff Development Coordinator, Assistant Director of Nursing, Director of Nursing or Clinical Nurse Consultant. • Monitoring of completed checklist for review will be completed during the daily clinical meeting, Monday through Friday X 8 weeks and then 3 X week x 8 weeks, to assure that all tasks have been completed as indicated. This review will be completed by the Unit Directors, Staff Development Coordinator, Assistant Director of Nursing, Director of Nursing. • Findings of the reviews will be reported to the facility's Quality Assurance and Assessment Committee. Any abnormalities or concerns identified will be immediately addressed and corrected with re-education as needed. • On [DATE] from 11:00 A.M. to 11:20 A.M. interviews with Licensed Practical Nurse (LPN) #180, LPN #640 and LPN #890 revealed each employee had received training related to new policies on Admission, Transfers and Discharges along with proper AMA procedures. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] and was transported home on [DATE] per emergency medical services. Resident #94 had diagnoses including respiratory failure, protein-calorie malnutrition, osteomyelitis, cerebral infarction, sepsis, COVID-19, arthropathy, gout, and dementia. Review of a hospital admission report, dated [DATE] revealed the resident was admitted with diagnoses including a weak cough, shortness of breath, and hypoxia. The resident was assessed to have bilateral leg contractures, bilateral hand contractures, and a Stage IV sacral wound that required daily dressing changes. The hospital report also noted the resident was alert to self, and unable to determine place or time. The resident was discharged from hospital for short-term (nursing home) placement. Review of the plan of care, dated [DATE] and updated [DATE] after resident's admission, revealed the resident had a discharge plan of care related to knowledge deficit for possible discharge home. Interventions included assistance with obtaining prescriptions, arranging transportation as needed, discuss with resident/representative the amount of assistance needed, evaluate resident's motivation to return to the community, make arrangements regarding community support, and provide contact numbers for community referrals. Review of Social History and Discharge Plan, dated [DATE] revealed the resident was oriented to self and able to answer some historical questions but does not seem aware of her condition or prognosis at the time of admission to the facility. Living arrangements noted the resident was living in her daughter's home, and also noted after this recent hospitalization, the daughter stated the resident has become more care than she can give. Review of a nursing assessment, dated [DATE] at 2:19 P.M. revealed the resident was alert and oriented to person and staff were unable to determine if the resident was alert to time or situation. The resident had short term memory impairment and impaired decision-making abilities. Review of the comprehensive 5-day Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #94 a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Resident # 94 was assessed to have short-term and long-term memory problems. The resident was also assessed to have the inability of identifying the current season, location of her room, staff names and faces, or that she was in a nursing home. The assessment indicated Resident #94 was dependent on two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of nursing assessment dated [DATE] at 1:48 P.M. revealed the resident was alert and oriented to person and staff were unable to determine if the resident was alert to time or situation. Resident responded to name but did not answer questions when asked. Review of a social service assessment, dated [DATE] at 2:54 P.M. revealed the resident was alert to self but refused to respond to multiple assessments. Additionally, the resident had a diagnosis of dementia so there was an assumption of both short-term and long-term memory loss. The resident was also documented as needing assistance with decision making. Review of a physician progress note, dated [DATE] revealed the resident was alert and pleasantly confused. A complete review of systems was limited due to dementia, and the resident was unable to provide a meaningful history at the time this assessment was conducted. Review of a social service (SS) note, dated [DATE] revealed Social Services Director #470 spoke with the daughter of Resident #94 on this date and discussed the possibility of palliative care. The daughter was also informed the resident's 20th day in the facility would be on [DATE]th, and that insurance would decrease payment to 80 percent of her bill with no source of secondary insurance. The note revealed the Social Service Director then explained they could apply for Ohio Medicaid, pay privately, or the resident could return home. The note indicated the daughter was to discuss the options with family members. Review of a social service note, dated [DATE] at 12:37 P.M. revealed the family wanted to take the resident home. However, the note also revealed a previous hospice provider was documented as refusing take the resident as a patient due to previous problems with the family and medication issues (at home). Another provider was suggested but was declined with the daughter stating she could not take care of her mom. The note revealed family was then agreeing to apply for Medicaid services with the resident staying at the facility. Review of a social service (SS) note, dated [DATE] at 12:44 P.M. revealed Social Service Director (SSD) #470 notified the Administrator and Director of Nursing Resident #94 was no longer discharging to her home. Review of a social service note, dated [DATE] at 2:56 P.M. revealed the family of Resident #94 had changed their mind and would be taking the resident home via voicemail received by the facility. The note indicated SSD #470 attempted to contact resident family members with no success and indicated the facility does not know how the resident will be transported home, and all discharge arrangements were canceled due to previous conversations with the resident planning to remain at the facility. The note revealed staff did not think this was a safe discharge, and that Hospice had declined to take the resident as they had indicated the resident's home situation was unsafe. The note revealed an AMA form was completed and ready for family to sign when they take the resident from the facility. Review of a social service (SS) note, dated [DATE] at 4:01 P.M. revealed SS was finally able to get in contact with resident's daughter. She confirmed her sister was going to pick up the resident and take her home (on this date) today. SS reminded the daughter that this was the last day the resident could reside in the facility without another payer source, and she stated she understood. The note indicated SS had talked to her (the daughter) about applying for Medicaid, which family declined to do. Social Service has made follow-up appointments for the resident's Primary Care Physician (PCP) and Wound Care and was waiting to see if home health would pick the resident up for their services. Review of a social service note, dated [DATE] at 8:12 A.M. revealed the resident was not picked up by her family last night as they stated they would. The resident was now remained in the facility without a payer source. Social Services had explained this to the resident's daughter multiple times. Social Service attempted to contact both daughters this morning and received a message that neither of their voice mail systems had been set up. The note indicated, will continue to contact them. Review of a physician note, dated [DATE] at 9:43 A.M. revealed the resident was seen and diagnosed with cellulitis to her right upper extremity, and received treatment with the antibiotic, Doxycycline 100 milligrams (mg) by mouth twice daily for seven days. The note revealed the resident's cognition remained at baseline per previous documentation. The resident was alert to person and place with abnormal memory and recall. Review of a physician's orders revealed an order, dated [DATE] for Doxycycline 100 mg by mouth twice daily for seven days. This was provided for a new diagnosis of right upper arm cellulitis. The resident was also documented as being septic when the antibiotic was prescribed. Review of a social service note, dated [DATE] at 3:30 P.M. revealed social service staff had continued to attempt to contact resident's daughters. SS was finally able to talk to daughter again, who stated she only had a moped and another family member had two flat tires on their vehicle. The daughter stated she would call back in 10 minutes, but SS still had not heard from her. SS talked to Administration about this and was told the facility should wait until Monday [DATE], and if family had not yet come to get Resident #94, then the facility should contact Adult Protective Services (APS) and the Ombudsman. The note revealed it was agreed this discharge would be Against Medical Advice (AMA). However, the note did not include any additional information as to how or why the discharge was an AMA discharge. Review of a nursing note, dated [DATE] at 1:32 P.M. revealed Resident #94 discharged home today and was transferred via stretcher per Patriot ambulance service. The resident was unable to sign AMA paperwork due to her bilateral hands being contracted. No family members were present to give discharge instructions to. The note indicated staff spoke with family via phone. Discharge medications and an instruction summary were sent with resident. The resident was to receive home health per Amedisys. Follow up appointments date, time, and phone number were sent to the family. All departments notified of discharge. Review of the Against Medical Advice form revealed the form was documented as being provided on [DATE] and was unsigned by the resident or family members. The signature block reflected the resident was transported by Patriot Ambulance Service and family was not present. The bottom of the form reflected Resident #94 was unable to sign the document due to bilateral hand contractures. No facility staff signature was evident on this form. Review of a social services note, dated [DATE] at 1:34 P.M. revealed Resident #94 was discharged to her home by ambulance on [DATE]. She was admitted to this facility on [DATE] from the hospital where she had presented to the emergency department with shortness of breath, a weak cough, and hypoxia. She came to this facility for post-hospitalization rehabilitation with plans to return to her home. While at this facility, she did not participate much with any of the therapy services and did not allow other departments to do a lot of the stuff they were required to do. On multiple occasions, the resident refused to allow SS to complete any of the assessments that were required. When her insurance cut her services, as was expected and had been explained to family, there was significant confusion between the daughters about whether or not Resident #94 was returning home or staying at the facility and applying for Medicaid. Staff had great difficulty in contacting family as they would not answer their phones, nor would they make decisions. On the day the resident was supposed to discharge, social services finally was able to contact the daughter, who stated she only had a moped to bring her mother home. She stated she would talk to family and call SS back in 10 minutes. SS never heard back from her. Over the weekend, family made arrangements for the resident to be taken home by ambulance. There was no one to sign the AMA paperwork. The note revealed staff did not feel this was a safe discharge and attempted to have AMA papers signed, but the resident was unable to do so and family was not present. Family had been informed this discharge would be AMA. Social Services contacted Kentucky Adult Protective Services and made a report of concern. Staff attempted to set up Community Hospice, but they would not admit the resident due to past experience with the resident's family and missing medications. SS was able to make a referral for Skilled Physical Therapy (PT) and Occupational Therapy (OT) and nursing with Amedysis Home Health. Durable Medical Equipment was ordered from WeCare Medical to be delivered to Resident #94's home. A follow up appointment was made with Physician #799. The note indicated social services staff would make a post discharge follow up phone call. Telephone Interview with Amedysis Representative #1000 on [DATE] at 03:16 P.M., revealed a referral was made by the facility on [DATE] and multiple calls were made to get into contact the family of the resident without success. The agency also attempted to complete a drive-by which was also not successful to make contact. Representative #1000 revealed their agency had received information the resident had expired on [DATE], and the ca