Failure to Complete Discharge Planning and Permit Return After Acute Care Transfer
Penalty
Summary
The facility failed to complete discharge planning and did not permit a resident to return after an acute care transfer. The resident, who was cognitively intact and had capacity for medical decisions, had a complex medical history including peripheral vascular disease, COPD, congestive heart failure, dementia with behavioral disturbances, and other chronic conditions. The resident had a documented history of inappropriate sexual behaviors and other physical and verbal behaviors toward staff and other residents. On the date of the incident, the resident was sent to an acute care facility following another episode of inappropriate sexual behavior. Despite being medically and psychiatrically cleared at the acute care facility, the resident was not allowed to return to the facility. There was no active discharge planning in place, and the facility had only made referrals to other facilities several months prior, with no further follow-up. Interviews with the DON and Administrator confirmed that the decision was made not to allow the resident to return, and that no additional discharge planning or supervision measures were implemented at that time.