Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who wished to return to the community when medically cleared. The resident's discharge plan was not evaluated, and her wish to return to the community was not honored. An involuntary hospital transfer was rescinded, but the facility did not document any attempts to ensure a safe and orderly transfer back to the facility. The resident remained in the hospital for an additional 17 days awaiting an appropriate discharge location, and the bed hold agreement was not honored without documentation of the cause. The resident, who had a history of psychiatric conditions including PTSD, conversion disorder, depression, schizophrenia, anxiety, bipolar disorder, and insomnia, was admitted to the hospital for altered mental status and aggressive behavior. Despite being deemed stable and cleared to return to the facility by the hospital's psychiatry services, the facility's administrator refused to accept the resident back, citing previous aggressive behavior. The facility did not respond to multiple attempts by the hospital to contact them regarding the resident's discharge. The facility's policy required notification and preparation for transfer or discharge, but the Nursing Home Transfer and Discharge Notice for the resident was incomplete and lacked necessary signatures. The facility's failure to follow its own procedures and communicate effectively with the hospital resulted in the resident being discharged to another long-term care facility instead of returning to the original facility.
Plan Of Correction
1. Resident #2 was discharged to the hospital due to endangering herself or others in the facility. Resident #2 did not return to the facility. 2. Administrator/designee reviewed all discharges in the last 3 months to ensure discharge preferences were followed, bed hold agreements were completed, and Nursing Home Transfer and DC Notice forms were completed. 3. Administrator/Designee educated licensed nurses and Social Services Director to ensure Discharge policies and procedures are followed. Administrator/Designee will conduct daily audits to ensure residents' Discharge Care Plan was followed, bed hold, and Nursing Home Transfer & DC Forms are completed accurately for 4 weeks and then 3 times weekly for 3 months or until substantial compliance is achieved. 4. Administrator/Designee to report all audit findings to monthly QAPI meetings for 3 months or until substantial compliance is achieved.