Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was admitted with multiple diagnoses, including Autistic Disorder, Epilepsy, Dysphasia, and Cognitive Communication Deficit Disorder. Upon admission, the resident arrived without medications, a medication list, personal items, and was soiled. The facility did not receive adequate communication from the discharging facility regarding the resident's behavioral issues, specifically sexually inappropriate behaviors, which were not documented on the face sheet or communicated prior to transfer. After admission, the resident exhibited sexually inappropriate behavior toward female staff, which the facility was unprepared to manage. The Director of Nursing and Administrator determined they could not meet the resident's needs and decided to return the resident to the original facility. The process was not coordinated, and the original facility refused to readmit the resident, leading to involvement from the police and Adult Protective Services. The resident ultimately was sent to the hospital due to lack of placement. The facility's actions did not follow their own Transfer and Discharge policy, which requires written notice, documentation of the reason for transfer or discharge, and communication with the resident, their representative, and the Long-Term Care Ombudsman. The discharge was rushed, lacked proper documentation, and failed to ensure the resident's safety and continuity of care, resulting in the resident being left without appropriate placement.