The October incident exposed gaps in how the facility handles discharges. Staff knew the resident wanted to leave and had them sign the required against-medical-advice form, but then failed to follow their own procedures for documenting the departure.
The director of nursing told inspectors on October 23 that the AMA form "was in the SW's office, and she found it in her office and it should be uploaded to PCC." The form never made it to medical records staff, who remained unaware of the resident's discharge.
Federal inspectors found the facility violated requirements for proper discharge documentation during their November 19 complaint investigation.
The social worker confirmed she obtained the resident's signature on the AMA form but admitted she "didn't give AMA to medical records staff." She acknowledged that documentation "should be uploaded in the system so that everyone could see."
According to the director of nursing, proper procedure requires getting a doctor's order for discharge, having the resident sign an AMA form, ensuring transportation is arranged, and involving the social worker to set up outpatient care needs. The resident should also receive education about leaving against medical advice.
The director said a physician order to discharge the resident home was entered at 1:00 PM, but "it looked like the nurse entered the orders after the resident left." She explained that while the facility cannot prevent residents from leaving, staff must complete proper documentation when they do.
"We get the form signed if the resident wants to leave and we do education," the director told inspectors. "We cannot stop them."
The social worker described her typical process for AMA discharges: contacting the resident by phone if possible, notifying the doctor through nursing staff, following up on safety concerns, and documenting everything in progress notes. She said she "would typically have a note on why the residents left."
But in this case, the documentation chain broke down. The social worker kept the signed form instead of forwarding it to medical records for proper filing and electronic upload. Medical records staff had no knowledge of the discharge.
The facility's own policy, last revised in October 2022, requires specific documentation when residents are transferred or discharged. This includes recording the date and time of discharge, a summary of the resident's medical condition, and the signature of the person documenting the information in the medical record.
The director of nursing acknowledged the facility doesn't typically follow up with residents who leave AMA, though she said "it would be nice if someone in corporate to check on them." She emphasized that "we hold everyone accountable" and that AMA forms should be given to medical records for proper uploading.
The resident was never entered into the discharge assessment system, leaving no official record of their departure in the facility's main documentation platform.
The social worker told inspectors that proper communication is essential: "Everyone keeps each other in the loop." But the October incident showed that system failing, with critical discharge documentation isolated in her office rather than integrated into the resident's official medical record.
The breakdown occurred despite the facility having established procedures for AMA discharges. The director of nursing could recite the proper steps but acknowledged they weren't followed completely in this case.
Federal regulations require nursing homes to maintain accurate, complete records for all residents, including proper documentation of discharges whether planned or against medical advice. The missing paperwork left gaps in the resident's care record and prevented other staff from accessing important information about the departure.
The October 22 discharge highlighted how communication failures between departments can compromise record-keeping even when staff understand the required procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Houston from 2025-11-19 including all violations, facility responses, and corrective action plans.