Failure to Readmit Resident After Hospital Transfer and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to readmit a resident after transfer to a VA hospital for medication evaluation and adjustment, despite informing the resident's responsible person that a bed would be held and the resident could return following hospitalization. Documentation for the transfer indicated it was necessary for the resident's welfare and that the resident's needs could not be met at the facility, but did not specify which needs could not be met or what attempts were made to address those needs. Key sections of the transfer/discharge notice were left blank, and there was no documentation supporting the facility's claim that the resident's behavior endangered the safety or health of others. Interviews with facility staff revealed inconsistencies in communication regarding the bed hold policy and the resident's eligibility for readmission. The responsible person was told a bed would be held, but the business office manager later stated that information about bed hold payment was not provided because the resident would not be readmitted. The administrator cited behavioral issues as the reason for declining readmission, but this was not documented in the transfer or discharge records, nor in the physician's discharge summary. The facility's own policy indicated that residents should be allowed to return if eligible and requiring skilled nursing services, but this was not followed in this case.