Resident Denied Readmission Without Proper Assessment After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident who was transferred to a general acute care hospital was properly evaluated for readmission and was denied return to the facility without adequate assessment. The resident, who had a history of schizoaffective disorder and unspecified psychosis, was initially admitted with intact cognitive skills and required supervision or assistance with daily activities. The resident was transferred to the hospital after an incident where he hit his roommate, which was the first occurrence of such behavior. Despite this, the facility did not document any efforts to determine if the resident's needs could still be met or if he continued to pose a danger to others upon potential return. Interviews revealed that the DON instructed hospital case workers not to return the resident, citing danger to others, but admitted there was no documentation or assessment to support this decision. The DON also acknowledged that the facility's interdisciplinary team made the decision without reviewing hospital reports, treatment plans, or consulting the resident's physician. The facility's policy required a review of the discharge plan, current condition, care needs, diagnosis, treatment plan, and behavioral or psychosocial support needs, but this process was not followed in this case.