Failure to Ensure Safe and Appropriate Discharge for Resident with Behavioral Needs
Penalty
Summary
A resident with severe cognitive impairment, including non-Alzheimer's dementia, Pick's disease, and aphasia, was admitted to the facility with a history of significant behavioral issues such as wandering, incontinence in inappropriate places, hypersexuality, and aggression toward staff and other residents. Upon admission, the resident's sister, who was also the POA, reported a decline in the resident's condition and behaviors. Facility staff communicated to the sister that the admission would be on a trial basis, and if the resident's behaviors could not be managed, alternative placement would be sought, with the expectation that the sister would take the resident back if necessary. Over the course of the resident's stay, the facility documented ongoing behavioral challenges, including physical aggression that resulted in injury to staff. Multiple referrals were sent to other care centers in an attempt to secure alternative placement, but these efforts were unsuccessful. On one occasion, after the resident exhibited aggressive behavior, including choking a CNA and hitting a nurse, the facility sent the resident to the hospital via ambulance for medication adjustment. The facility then informed the resident's sister and the hospital that the resident would not be accepted back, and provided a list of potential alternative facilities, most of which were out of state or not appropriate for the resident's needs. The facility did not coordinate with the hospital to evaluate the resident for possible return or ensure a safe and appropriate discharge plan. The hospital social worker reported a lack of further communication from the facility regarding the resident's placement, and the resident ultimately remained in the hospital until a short-term psychiatric facility out of state was found. The resident's sister expressed concern that the facility had not secured a new placement and had effectively abandoned the resident at the hospital, resulting in a period of instability and difficulty in finding appropriate care.