Failure to Permit Resident Return After Hospitalization Due to Financial Documentation Requirement
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite the resident being clinically ready for readmission and having an anticipated return documented in the Minimum Data Set (MDS). The resident, who had acute and chronic respiratory failure and a tracheostomy, was initially admitted to the hospital for abnormal lab results and subsequently diagnosed with sepsis. The resident's payor source was documented as Medicaid pending, and the facility's policy indicated that Medicaid pending residents are to be treated as Medicaid approved for the 15-day bed hold period, after which the non-Medicaid process applies. During the resident's hospitalization, there was no evidence in the clinical record that the facility inquired about the resident's discharge plan or return status. Hospital case management staff reported that they repeatedly contacted the facility to arrange the resident's return after completion of antibiotic treatment, but the facility required financial statements from the resident or representative as a condition for readmission. Text message communications and interviews with facility staff confirmed that financial information was made a prerequisite for the resident's return, even though the transfer to the hospital was for medical reasons. Despite the hospital faxing clinical records multiple times and the facility having open beds available, the facility did not review the records or accept the resident back. The administrator and facility liaison both confirmed that financial information was required prior to readmission. This action was not in accordance with the facility's own bed-hold policy and state regulations, resulting in the resident not being permitted to return to the facility after hospitalization.