Failure to Permit Return of Hospitalized Resident After Psychiatric Clearance
Penalty
Summary
The facility failed to permit the return of a resident following hospitalization, despite clearance from a psychiatrist for transfer back to the facility. The resident, who had a history of acute kidney failure, liver disease, and peripheral vascular disease, was initially transferred to the hospital after displaying aggressive behavior toward other residents and staff, which resulted in a 911 call and a 5150 psychiatric hold. Hospital records indicated that after evaluation, the resident was not considered a danger to self or others and was cleared for return to the facility. However, facility staff, including the DON and Marketing Coordinator, confirmed that the resident was not evaluated at the hospital for return eligibility, and the decision not to accept the resident back was made based on prior behavior rather than current clinical status. Facility policy required that residents be evaluated based on their current condition at the time of potential return, not on the circumstances that led to their initial transfer. Despite this, the DON instructed staff not to accept the resident back, citing concerns for the safety of other residents due to the resident's previous aggressive actions. The facility's failure to follow its own policies and procedures regarding bed-holds and return evaluations resulted in the resident's delayed transfer to another skilled nursing facility and possible disruption of care.