Failure to Permit Resident to Remain and Inadequate Discharge Documentation
Penalty
Summary
Facility staff failed to permit a resident with multiple complex diagnoses, including seizures, COPD, hypertension, anxiety, heart failure, a history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance, to remain in the facility. The resident had moderate cognitive impairment and required maximum assistance for most activities of daily living. Despite the resident's preferences for certain activities and his non-ambulatory status, the facility initiated a transfer to the emergency room following an incident where the resident reportedly exhibited behavioral issues, including hitting staff and making threats. However, documentation from hospice and EMTs indicated that the resident was calm and non-combative during their assessments, and the resident expressed a desire not to be transferred to the hospital. The facility administrator cited a policy requiring ER evaluation for aggressive behaviors, but the current administrator later clarified that this was not a formal policy but rather a section in the admission agreement. The facility issued a 30-day discharge notice after learning more about the resident's psychiatric history, despite a care plan being developed in collaboration with hospice to address his needs. Interviews with hospice staff revealed that the facility did not attempt to implement the agreed-upon interventions before issuing the discharge notice. The discharge notice cited the facility's inability to meet the resident's needs and concerns for the health, safety, and well-being of others, but there was no documentation of specific needs that could not be met or of attempts to address those needs as required by facility policy. Medication management for the resident was also inconsistent, with delays in starting prescribed medications and some orders not being administered as intended. Staff interviews indicated that while the resident had some behavioral incidents, there was no evidence that he attempted to harm other residents. The facility's own assessment stated that it could care for residents with psychiatric and behavioral needs, yet the documentation and actions taken did not reflect adequate attempts to meet this resident's needs prior to discharge. The required documentation supporting the discharge, including specific unmet needs and efforts to address them, was not found in the medical record.