Failure to Prevent Unnecessary and Abrupt Discharge of Resident with Dementia
Penalty
Summary
The facility failed to prevent an unnecessary and abrupt discharge of a resident with dementia, resulting in significant emotional distress and increased behavioral symptoms. The resident, who was severely cognitively impaired and had a history of dementia with behavioral disturbances, was familiar with the facility environment and had established routines that helped manage his anxiety and agitation. Despite this, the facility's interdisciplinary team, including the Nursing Home Administrator and Director of Nursing, decided to seek a transfer for the resident due to concerns about his wandering and interactions with other residents, particularly after another resident verbally threatened him. However, the only intervention implemented was increased staff supervision as available, and there was no evidence of individualized care or additional interventions to address the situation within the facility. Interviews with staff indicated that the resident's behaviors were manageable and that he was easily redirected. The care plan included strategies such as involving the resident in one-on-one activities and maintaining a predictable routine, but there was no documentation of new or enhanced interventions to address the reported concerns. The resident's representative was not given the option to appeal the discharge and was only informed of the transfer on the day it occurred. The facility did not provide documentation of efforts to address the behaviors of the other resident who was threatening the discharged resident, nor did they pursue additional resources or support due to the absence of a social worker at the time. Following the abrupt transfer to a locked memory care unit, the resident experienced increased anxiety, agitation, and emotional distress, requiring pharmacological intervention. Reports from the receiving facility and the resident's representative indicated that the resident became physically aggressive, more combative, and required multiple psychotropic medications to manage his intensified behaviors. The facility's discharge policy required specific documentation and notice, including the basis for discharge and efforts to meet the resident's needs, but there was no evidence that these requirements were met. The lack of individualized care and failure to prepare the resident for a safe and appropriate transfer led to significant psychosocial harm.