Failure to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return following hospitalization, which was evident for one of six residents. The resident was initially transferred to the hospital for severe dysphagia evaluation and possible feeding tube placement. Despite the hospital's assessment that a feeding tube was not necessary, the facility refused to readmit the resident, citing care needs exceeding their current capacity. The facility did not provide the resident or their representative with a written notice of discharge, including notification of appeal rights, nor did they notify the Long-term Care Ombudsman. The facility's policies on admissions and discharge planning did not address the protocol for residents transferred to the hospital but not accepted back. The resident, who was cognitively intact, had been admitted with a diagnosis that included dysphagia. The facility's interdisciplinary team, including a medical doctor, determined that the resident was at high risk for aspiration and recommended hospital transfer for further evaluation. However, the facility did not follow the required procedure for discharge notification, failing to issue a 30-day notice with appeal rights. Interviews with the resident's representative and facility staff revealed that the decision not to readmit the resident was based on the facility's assessment of the resident's care needs and risk for aspiration. The medical team, including the medical director, reviewed the hospital's patient review instrument and decided against the resident's return. Despite discussions with the resident's family about the risks and necessary precautions, the facility did not document or communicate the discharge decision appropriately, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. 2. The Director of Social Service was given an educational counseling and a 1:1 inservice on discharge protocol emphasizing that the resident / resident representative and the Long-term Care Ombudsman is notified of the discharge in writing, including notification of appeal rights. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service compiled a list of residents in the last 30 days who have been discharged from the facility. The list was reviewed to ensure that each resident / resident representative in addition to the Long Term Care Ombudsman was notified of the discharge in writing, including notification of appeal rights. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS and Director of Social Service reviewed and revised the policy on “Discharge Planning: Discharge Notification to Resident / Family” to include a protocol for a resident who was transferred to the hospital from the facility but is not being accepted back into the facility. The protocol includes that the resident / resident representative in addition to the Long Term Care Ombudsman will be notified of the discharge in writing, including notification of appeal rights. 2. The Director of Social Service and the social workers will be in-serviced on the revised policy “Discharge Planning: Discharge Notification to Resident / Family” by the administrator / designee with emphasis on ensuring that each resident / resident representative in addition to the Long Term Care Ombudsman are notified of the discharge in writing, including notification of appeal rights. 3. The Administrator, Medical Director, DNS and Director of Social Service reviewed the policy on “Admission Process” including not being able to accept a resident if the facility cannot provide adequate or appropriate care for that resident and found it to be compliant. 4. The Director of Admissions, Director of Social Service and the social workers will be in-serviced on the policy by the administrator regarding “Admission Process” by the administrator / designee with emphasis on appropriate admissions to the facility depending on the resident’s level of care. 5. A copy of the Lesson Plan and Attendance is filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that the resident / resident representative as well as the Long Term Care Ombudsman is notified in writing regarding the discharge including the notification of appeal process. 2. Audits will be done by the Director of Social Service/Designee on 10 random discharges weekly x 4 weeks, 10 random discharges monthly x 3 months and 10 random discharges quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible to ensure correction of this deficiency by 4/7/2025.