Failure to Allow Resident Return and Inadequate Discharge Process
Penalty
Summary
A deficiency occurred when the facility failed to allow a resident to return after a hospital stay, without providing documented evidence that the resident's needs could not be met. The resident, who had a court-appointed guardian, had multiple diagnoses including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of attention-seeking behaviors and statements of self-harm, which were being managed through monitoring, therapy, and medication adjustments. Despite these interventions, the facility decided not to readmit the resident after a psychiatric hospital stay, citing concerns about ongoing suicidal ideation (SI) and the belief that the resident required a higher level of care. The facility initiated referrals to other skilled nursing facilities (SNFs) while the resident was still at the mental health hospital, and ultimately transferred the resident to another SNF without providing a documented reason that the resident's needs could not be met at the original facility. Communication records show that the guardian did not agree to a permanent transfer and expected the resident to return if no alternative placement was found. The facility did not provide a 30-day discharge notice, discharge instructions, or information about the right to appeal or contact the Ombudsman, as required by regulations. The guardian reported feeling pressured to accept the new placement due to the facility's refusal to readmit the resident. Interviews with facility staff, the guardian, and hospital staff confirmed that the facility had previously managed the resident's SI and behaviors with interventions such as one-on-one monitoring and medication adjustments. Staff acknowledged that there was no emergency requiring immediate transfer and that the facility could have continued to care for the resident. The decision to transfer was made without proper discharge planning, documentation, or regulatory notifications, and the accepting SNF was not screened to ensure it could meet the resident's needs. The lack of a documented reason for non-readmission and failure to follow required discharge procedures led to the deficiency.