Failure to Reassess and Coordinate Discharge for Hospitalized Residents
Penalty
Summary
The facility failed to adhere to all required components of the discharge process for three residents who were found to be medically stable and no longer a safety risk after being transferred to the hospital. Documentation and interviews revealed that, although immediate discharge notices were provided to guardians and the ombudsman, the facility did not reassess the residents' conditions after hospitalization to determine if their needs could be met upon return. The facility also did not collaborate with guardians or hospital staff to facilitate the residents' return or alternative placement, despite requests and appeals from guardians and hospital case managers. For each of the three residents, the facility issued immediate discharge notices citing health and safety concerns, and transferred the residents to the hospital. The discharge letters included required information such as the reason for discharge, appeal rights, and ombudsman contact details. However, after the residents were stabilized in the hospital and deemed ready for return, the facility refused to reassess or accept them back, and did not engage in further communication or planning with the hospital or guardians regarding their return or alternative placement. Guardians and hospital staff reported a lack of follow-up and communication from the facility, and appeals were filed in response to the discharges. The residents involved had significant psychiatric and medical histories, including diagnoses such as vascular dementia, paranoid schizophrenia, bipolar disorder, and Wernicke's encephalopathy. Despite being medically cleared for return by hospital staff, the facility maintained its decision not to readmit the residents, and did not provide evidence of reassessment or efforts to ensure safe and appropriate discharge planning. The ombudsman confirmed receipt of discharge notices and ongoing appeals, with all three residents remaining in the hospital awaiting further placement.