Failure to Provide Proper Discharge Notice and Refusal to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to provide an appropriate discharge notice and did not allow a resident to return after a hospital transfer, nor did it secure an alternate placement. The resident in question had a complex medical and behavioral history, including dementia, metabolic encephalopathy, PTSD, selective mutism, chronic kidney disease, and suicidal ideations. The resident had a documented pattern of aggressive behaviors toward other residents, resulting in multiple incidents and interventions such as one-on-one observation and psychiatric evaluations. On the day of the incident, the resident was transferred to a hospital for medical clearance for psychiatric admission due to combative and aggressive behavior. The facility issued a discharge notice indicating the resident was being discharged to the hospital because his or her needs could not be met and for the safety of others. However, the discharge process was not handled in accordance with policy and regulatory requirements. The Ombudsman was not properly notified of the discharge, and there was confusion among staff regarding the type and timing of the discharge notice. The Social Services Director was unsure whether the notice was a 30-day or immediate discharge and did not initially send referrals to other facilities, believing the resident would return. Subsequently, the facility decided not to allow the resident to return after the hospital stay, and staff communicated this to the hospital and the resident's family. Referrals to other facilities were sent only after several days, and the hospital had difficulty finding a new placement for the resident. Interviews with facility staff, including the ADON, Social Services Director, Clinical Liaison, DON, and Administrator, revealed a lack of coordination and understanding of the discharge process, as well as an acknowledgment that the facility was required to allow the resident to return but did not do so.