Failure to Provide Appropriate Emergency Discharge and Safe Transfer Location
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and did not secure a suitable location for transfer when a resident was ready to discharge from the hospital. According to the facility's own Discharge and Transfer - Involuntary Policy, residents must not be transferred or discharged unless specific criteria are met, and the facility must ensure a safe and orderly transfer, including allowing the resident to participate in the decision of where to transfer. In this case, staff documented an immediate discharge notice for a resident due to aggressive behavior toward another resident, indicating the resident would be discharged to the local hospital. Interviews revealed that the administrator acknowledged the resident was too aggressive to remain at the facility and admitted there was an issue with the hospital not being an appropriate long-term placement. The resident's guardian confirmed that the facility issued an emergency discharge to the hospital, which was not a safe long-term solution, and stated that the facility would not allow the resident to return. The guardian also noted difficulty in finding alternative placement due to the resident's complex diagnoses.