Failure to Ensure Safe and Justified Resident Discharge
Penalty
Summary
A resident with multiple chronic conditions, including congestive heart failure, COPD, pressure ulcer, chronic osteomyelitis, polyneuropathy, chronic pain syndrome, and depressive disorder, was admitted to the facility and assessed as cognitively intact with moderate depression. The resident had a history of verbal aggression, but there was no care plan addressing physical aggression. On the day of the incident, the resident became verbally aggressive and threatened staff after being informed of a new roommate assignment, following a previous altercation with a former roommate. Staff attempted to de-escalate the situation, but the resident continued to display verbal aggression and made threatening remarks. The police were called, and the resident was taken to the hospital for evaluation, with staff citing outstanding warrants as a reason for police involvement. The facility initiated an emergency discharge, citing the resident's behavior and the police intervention. However, documentation and interviews revealed inconsistencies regarding the resident's physical aggression, with several staff members and the resident's sister stating that the resident was not physically aggressive, only verbally so. The facility did not provide clear supporting rationale or documentation for the discharge, and the clinical record lacked evidence that the resident's needs and preferences were considered or that the resident was prepared for a safe transfer or discharge. The resident was not offered the opportunity to return to the facility after hospital observation, despite not being arrested, and was instead released to a family member. The facility's actions did not align with its own transfer/discharge policy, which requires that a resident may only be discharged if their needs cannot be met, their health has improved, or the safety or health of others is endangered. The lack of documentation supporting the discharge decision, failure to provide adequate notice, and not allowing the resident to return after hospital observation constituted a deficiency in ensuring that the transfer/discharge met the resident's needs and preferences and that the resident was prepared for a safe transition.