Failure to Meet Resident Needs Prior to Emergency Discharge
Penalty
Summary
The facility failed to make adequate attempts to meet the needs of two residents prior to issuing emergency discharges following a series of resident-to-resident altercations. Both residents had intact cognitive status, as indicated by their BIMS scores, and required varying levels of assistance with activities of daily living. The clinical records showed a pattern of verbal disputes and threats of violence between the residents and their peers, with interventions primarily consisting of moving residents to different rooms and de-escalating situations. On the date of the final altercation, the facility obtained orders for emergency psychiatric evaluations and arranged for both residents to be transferred to local hospitals. The process of discharge was initiated while the residents were at the hospitals, with the facility citing the safety of individuals in the facility as the reason for the emergency discharges. The discharge forms included information about placement and appeal rights, but there were lapses in communication with the residents' guardians and family members. One resident's guardian was not informed about the appeals process and did not receive any forms to sign, while the other resident's family could not be reached prior to the discharge. Both residents were ultimately not admitted to the hospitals for psychiatric reasons, and the facility refused to readmit them upon the hospitals' requests. Interviews with facility staff revealed that the decision to discharge was made due to a perceived lack of available rooms to accommodate residents with behavioral issues. The staff also demonstrated a lack of awareness regarding the proper notification and involvement of guardians in the discharge process. As a result, one resident remained hospitalized while the other was taken to his apartment by family members, with concerns noted about his ability to manage medications and daily living needs.