Failure to Provide Written Discharge Notice Upon Resident Transfer to Police Custody
Penalty
Summary
The facility failed to provide written notification of discharge to a resident and the resident's representative when the resident was transferred into police custody. The resident, who had a history of diabetes, chronic pain, and repeated falls, was cognitively intact as indicated by a BIMS score of 15. On the day of the incident, law enforcement arrived at the facility to take the resident into custody, and the Director of Nursing (DON) documented that all belongings and medical information were sent with the resident. However, there was no evidence that a written discharge notice was provided to the resident or their representative at the time of transfer. Interviews with facility staff, including the Social Worker, Administrator, and DON, revealed that the decision to discharge the resident was made based on information from law enforcement that the resident would remain in custody until trial. The staff acknowledged that the usual 30-day written notice for facility-initiated discharges was not given, and instead, verbal notifications and voicemails were left for the resident's Power of Attorney (POA) and the ombudsman. The facility also did not provide written documentation of the reasons for discharge in a language and manner understandable to the resident and their representative. Further review indicated that the facility's policies require written notice of discharge or transfer, including in emergency situations, and that such notices should be provided to the resident, their representative, and the ombudsman. Despite these policies, the facility did not issue the required written notice when the resident was taken into police custody and subsequently discharged. The ombudsman confirmed that the resident had previously appealed a discharge and won, and expressed that the resident should have been accepted back after the arrest and hospital stay, but the facility refused readmission based on its policy regarding registered sex offenders.