Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident, identified as Resident R50, to return to the facility after being transferred to the hospital with the expectation of returning. The facility's policy on bed-holds and returns, dated August 2024, outlines that residents and their representatives are informed in writing about the facility and state bed-hold policies, including the duration of the bed-hold, reserve bed payment, and return policy. Despite these policies, Resident R50, who was admitted to the facility in October 2021 and had diagnoses including anemia, hypertension, and quadriplegia, was not allowed to return after hospitalization. The facility cited the inability to meet the resident's needs as the reason for this decision. Interviews with facility staff revealed that the decision not to readmit Resident R50 was due to the resident's refusal of medications, tube feedings, and care, as well as the resident's and his mother's preference for oral intake against physician orders, which posed an aspiration risk. The Social Service Director and the Director of Nursing both confirmed these reasons, and the Nursing Home Administrator acknowledged the failure to permit the resident's timely return. This action was in violation of the facility's policy and regulatory requirements, as the resident was transferred with the expectation of returning to the facility.
Plan Of Correction
Resident R50 was not readmitted to the facility. Resident and mother's physiological and psychological behaviors that have impacted other residents and their rights. To ensure other residents were not affected by the deficient practice, an audit of facility-initiated discharges of the past 30 days will be completed by the DON or designee. The Regional Director of Clinical Support or designee will conduct education to the IDT Members: DON, Administrator, ADON, Social Service Director, the facility readmission policy and F-tag 626 requirements. The NHA or designee will audit all discharges to the hospital or LOA, and readmissions to ensure that all residents that discharged were allowed to return (or offered a bed hold per our Bed Hold policy). This will be done once a week for 3 months. Results will be reviewed at the QAPI meeting.