Involuntary Discharge Without Sufficient Documentation or Interventions
Penalty
Summary
The facility initiated a 30-day involuntary discharge for a resident with multiple complex diagnoses, including schizoaffective disorder, diabetes mellitus type 2, heart failure, visual loss, personality and behavioral disorders, and alcohol abuse. The resident's clinical record documented behavioral symptoms such as verbal outbursts, accusations, and occasional refusal of care, but there was no evidence in the record to validate the reason for the involuntary discharge. Specifically, the clinical documentation did not show that the resident's needs could not be met at the facility or that the resident had placed other residents in danger, which are required justifications for involuntary discharge. Throughout the review period, progress notes described the resident as having episodes of yelling, cursing, and making accusations against staff and other residents, as well as some physical actions like throwing a shoe and rolling a wheelchair into staff. However, the records consistently lacked documentation of interventions attempted to address these behaviors, and there were no investigative or incident reports regarding alleged inappropriate behaviors toward other residents. Staff interviews confirmed that while the resident was verbally aggressive and irritable, there were no known physical altercations with other residents, and all aggressive behaviors were primarily directed at staff. One administrative staff member reported a threat made by the resident toward another resident, but this was not recognized or reported as resident-to-resident abuse, and no incident report was filed. The care plan for the resident did not include discharge planning interventions prior to the issuance of the involuntary discharge notice. Additionally, the facility was unable to provide a policy related to involuntary discharge. The lack of documentation supporting the necessity of the involuntary discharge, absence of evidence that the resident's needs could not be met, and failure to document or attempt behavioral interventions led to the deficiency. The facility's actions did not demonstrate that the transfer or discharge met the resident's needs or preferences, nor that the resident was prepared for a safe transfer or discharge.