Failure to Provide Timely Discharge Planning and Capacity Assessment
Penalty
Summary
The facility failed to provide necessary social services by not promptly developing a discharge plan or seeking professional medical or psychiatric evaluations to determine if a resident, who was homeless and their own legal representative, had the right to discharge to the community, discharge against medical advice (AMA), or if legal guardianship should be pursued. The resident, with diagnoses including bipolar disorder and anxiety, was admitted from a hospital and placed on a locked unit after expressing a desire to leave and attempting to do so. Despite repeated expressions of wanting to leave, confusion, and fluctuating cognitive status, there was no timely assessment or documentation regarding the resident's capacity to make discharge decisions or the appropriateness of their placement on a locked unit. The social services documentation was inconsistent and incomplete. Discharge planning reviews and care plans lacked critical information, such as the resident's living situation, support network, and overall summary of potential for discharge. There was no evidence that referrals to local contact agencies or community resources were made in a timely manner, and the care plan did not address the resident's placement on the locked unit or discharge planning. The psychiatric nurse practitioner was not asked to evaluate the resident's decision-making capacity until months after admission, despite ongoing concerns about the resident's ability to safely live independently and repeated requests to leave the facility. Interviews with staff revealed a lack of clarity regarding policies for seeking legal guardianship or managing residents on locked units. The social services department experienced turnover, further disrupting continuity of care and discharge planning. The resident continued to express a desire to leave, called 911 alleging being held against their will, and was found to have diminished capacity only after a delayed psychiatric evaluation. Throughout this period, the facility did not adequately coordinate or document efforts to address the resident's psychosocial needs, discharge planning, or legal status, resulting in a failure to provide necessary social services as required.