Failure to Ensure Safe and Proper Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a fair and proper discharge for a resident with significant cognitive impairments, including a history of stroke, encephalopathy, traumatic brain injury, and ongoing confusion and impulsivity. Documentation throughout the resident's stay indicated she was not capable of making her own decisions, required constant supervision, and was at risk for elopement. Despite these findings, when the resident attempted to leave the facility, staff treated the situation as an 'Against Medical Advice' (AMA) discharge without conducting an accurate assessment of her mental capacity to understand the implications of leaving AMA. The resident left the facility accompanied by staff, with police and EMS involvement after she was found walking on a highway. Upon arrival at the emergency department, the ED physician determined the resident was delusional and recommended her return to the facility, with agreement from the resident and her advocate. However, the facility refused to accept her back, citing her AMA status and erratic behavior, despite the ED physician and facility physician both expressing doubts about her capacity to make an AMA decision. The facility did not reassess the resident's condition or needs after she was cleared by the ED physician, and no documentation was provided to support that the facility could not meet her needs. As a result of the facility's actions, the resident experienced an extended hospital stay and was ultimately transferred to another facility located more than two hours away, limiting her advocate's ability to provide support. Interviews with staff and the resident's advocate confirmed that the resident was confused and unable to make informed decisions at the time of her departure. The facility's own policies and facility assessment indicated they were equipped to manage residents with cognitive and behavioral challenges, but these were not followed in this case.