Failure to Ensure Safe and Orderly Discharge Following Resident Assault
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including diabetes, dementia, anxiety disorder, and depression, was admitted to the facility and later became involved in a serious incident. The resident entered another resident's room, became physically aggressive, and assaulted an LPN by stepping on her foot and attempting to strangle her. The police were called, and the resident was arrested for aggravated assault and removed from the facility. Documentation shows that the facility issued an immediate discharge notice to the resident, citing endangerment to the safety and health of individuals in the facility. The facility's records indicate that after the resident's arrest, the discharge notice was delivered to the local detention center and sent to the resident and their representative by mail. The facility also notified the resident's son/POA about the arrest and discharge. However, there was no evidence in the medical record that the facility ensured the receiving facility (the detention center) could meet the resident's needs or that appropriate information was communicated to the receiving provider. Additionally, there was no documentation from a healthcare provider justifying the necessity of the discharge. A review of the facility's transfer and discharge policy requires that, in cases of discharge for safety reasons, the facility must document the transfer or discharge in the medical record and communicate appropriate information to the receiving care institution or provider. The policy outlines specific information that must be provided, such as practitioner contact information, resident representative information, advanced directives, special instructions, care plan goals, and other necessary information. The facility failed to meet these requirements in this case, as confirmed by interviews with the DON and ED, who stated that no further documentation was available.