Failure to Permit Return and Provide Required Discharge Notifications After Hospitalization
Penalty
Summary
The facility failed to ensure that three residents who were transferred to acute care hospitals for psychiatric evaluation were permitted to return to the facility after being deemed stable for discharge by hospital staff. In each case, the residents were not re-admitted to the facility, despite their readiness for return, and instead remained in the behavioral health facility or were transferred to other long-term care facilities. The facility required additional documentation and insurance authorization before considering re-admission, which resulted in the residents not being allowed to return. Additionally, there was no documentation in the medical records indicating that the facility was unable to meet the needs of these residents. The facility did not provide written notification to the residents, their responsible parties, or the Ombudsman regarding the transfer or discharge, nor did it inform them of their appeal rights as required by policy. Interviews with facility staff confirmed the absence of such documentation and notifications. The events involved residents with complex medical and psychiatric histories, including diagnoses such as acute kidney failure, dementia, schizophrenia, and behavioral disturbances. The lack of proper notification and failure to permit return after hospitalization were identified through record reviews and interviews with facility staff and external social workers.