Failure to Permit Return and Provide Required Discharge Documentation After Hospitalization
Penalty
Summary
The facility failed to permit two residents to remain in or return to the facility following hospitalization, as required by federal and state regulations. For one resident, there was no documentation in the chart indicating the reason for transfer to the hospital or the subsequent discharge process. The DON stated the resident was sent to the hospital due to pain after an incident involving muscle spasticity and shaking, but could not provide required documentation such as a bed hold or transfer/discharge notice. The resident was later transferred to a long-term acute care hospital, and when ready to return, the facility did not have a bed available. The administrator and admissions coordinator could not provide clear reasons for not readmitting the resident, and there was no evidence that the facility assessed bed availability or provided the necessary notifications. For the second resident, the chart indicated a transfer to the hospital for chest pain, but there was no further documentation regarding the resident's status or discharge process. The DON and admissions coordinator gave conflicting accounts, with the DON stating the resident chose to transfer to another facility, while the admissions coordinator referenced care needs and behavioral concerns as reasons for not accepting the resident back. Communication with the hospital revealed the facility cited care needs exceeding capacity and the resident being a danger to self and others, but the DON later stated the resident was not actually a threat and had not been involved in physical altercations. There was also no bed hold documentation or 30-day discharge notice provided for this resident. The facility's own policy requires that residents sent to acute care must be permitted to return unless specific criteria are met, and that appropriate documentation and notifications must be completed. In both cases, the facility did not follow its policy or regulatory requirements, as evidenced by missing documentation, lack of clear decision-making regarding readmission, and failure to provide required notices to the residents.