Failure to Permit Resident Return After Hospitalization
Penalty
Summary
A resident with multiple diagnoses, including chronic obstructive pulmonary disease, lung cancer, opioid dependence, anxiety disorder, hypertension, depression, and a history of alleged adult physical abuse, was admitted to the facility and later issued a 30-day discharge notice due to noncompliance with facility rules and a behavior contract. Despite the notice, the resident remained in the facility past the stated discharge date. The resident exhibited behavioral symptoms, including verbal outbursts and threats toward staff and other residents, and was involved in incidents that required police intervention. The facility's records show that the resident was sent to the hospital for a psychiatric evaluation following an escalation in behaviors, including possession of alcohol and threats, but there were no documented attempts to facilitate the resident's return to the facility after hospitalization. Interviews with facility staff confirmed that the decision not to permit the resident's return was made by facility leadership, despite awareness of the requirement to allow the resident to return after an acute care stay. The resident was ultimately discharged from the hospital to a homeless shelter, and the facility delivered his belongings there. The facility's own policy stated that residents transferred to acute care should be permitted to return upon discharge unless specific exemptions applied, but there was no documentation that these exemptions were met or that a safe discharge plan was ensured.