Lack of Physician Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a resident's Electronic Health Record (EHR) contained physician documentation of the rationale for an involuntary immediate discharge. The resident in question had a complex medical history, including Huntington's disease, anxiety, a history of suicidal behavior, and major depressive disorder. The resident exhibited behaviors such as physical and verbal aggression, self-harm, and rejection of care, which were documented in multiple staff progress notes and assessments. Despite these ongoing behavioral issues and repeated hospitalizations for psychiatric evaluation, the EHR lacked physician documentation specifying the services the facility was unable to provide or that the resident posed a risk to the safety of others. On the day of the discharge, the resident became acutely agitated, removed window blinds, expressed suicidal intent, and attempted to strangle himself with the blinds. Staff intervened, administered PRN medications, and called Emergency Medical Services (EMS) when the situation escalated. The resident was transported to a hospital for further evaluation and treatment. The facility notified the resident's representative and documented the discharge in the EHR, stating that the resident's needs could no longer be met and that he posed a safety risk to others. However, the discharge letter and EHR did not include physician documentation detailing the specific reasons for the discharge as required by facility policy. Interviews with administrative staff confirmed that the discharge was unplanned and that the facility had exhausted available resources to manage the resident's behaviors. The facility had attempted to refer the resident to specialized units, but these referrals were declined due to the resident's history of self-harm. Despite these efforts, the required physician documentation supporting the involuntary discharge was not present in the EHR, constituting a deficiency in meeting regulatory requirements for safe and appropriate resident transfer or discharge.