Failure to Ensure Safe and Compliant Discharge Process
Penalty
Summary
The facility failed to ensure a safe and regulatory-compliant discharge process for a resident who was transferred to the hospital following behavioral incidents. The resident, who had a history of depression, developmental delay, suicide attempt, skin graft failure, muscle contractures, and a permanent tracheostomy, exhibited escalating behaviors including yelling, cursing, threatening staff, and attempting to tamper with his tracheostomy device. Following these events, the resident was transferred to the hospital by EMS after expressing threats to harm staff. Despite the hospital determining the resident was stable and did not require inpatient admission, the facility refused to allow the resident to return, citing inability to meet his needs and concerns for the safety of others. The facility did not provide documentation from a physician agreeing to the discharge, nor did it include a physician's order for discharge or a physician's signature on the discharge form. The discharge notice was issued 11 days after the resident's transfer, and the section of the form for ombudsman contact information was left blank. Additionally, the facility listed a receiving facility for discharge, but that facility denied the resident's admission. There was no evidence in the medical record that the facility reassessed the resident for readmission after he was stabilized at the hospital and ready to return. Interviews with the resident's representative, hospital staff, and facility staff confirmed that the facility did not follow its own discharge policy or regulatory requirements. The resident's representative was not informed of the right to appeal the discharge, and the admissions assistant expressed discomfort with the discharge process due to lack of proper notice and documentation. The NHA acknowledged that not all regulations were followed in the discharge process, and efforts to place the resident in another facility were unsuccessful. The resident remained at the hospital at the time of the interviews.