Unsafe Discharge to Inappropriate Setting for Resident with High Care Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with severe cognitive impairment and significant behavioral issues. The resident, diagnosed with schizoaffective disorder bipolar type, psychosis, and manic episodes, required one-on-one supervision and substantial assistance with activities of daily living (ADLs) such as eating, toileting, and mobility. Despite these needs, the resident was discharged to an independent living facility that did not provide assistance with ADLs or behavior monitoring. The discharge summary and care plan documented the resident's need for close supervision and support due to behaviors including agitation, violence, and hallucinations. Upon arrival at the independent living facility, the resident became agitated and destructive, leading to a call to emergency services and subsequent transfer to a hospital. Interviews with facility staff and the independent living facility owner confirmed that the discharge was inappropriate, as the receiving facility was not equipped to meet the resident's care needs. The facility's own discharge policy required that all necessary information be provided to ensure a safe transition, but this was not followed, resulting in an unsafe discharge.