Failure to Ensure Safe and Appropriate Readmission Following Hospital Transfer
Penalty
Summary
A resident with multiple complex medical diagnoses, including hypertensive heart and chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder, was admitted to the facility for respite care under hospice services. The resident exhibited agitation and aggressive behaviors, such as tipping over furniture, banging objects, and attempting to access the medication cart. Staff documented these behaviors and contacted the physician, hospice nurse, and DON for guidance. Orders for PRN medications were obtained, but according to the Medication Administration Record, these were not administered. As the situation escalated, the DON instructed staff to call 911, and the resident was transferred to the hospital for evaluation and treatment. After being treated and cleared at the hospital, the resident was returned to the facility by EMS. Upon arrival, facility staff, under the direction of the DON, refused to allow the resident back into the building, citing concerns for staff safety. Police and fire department personnel were also present and attempted to facilitate the resident's return, but staff continued to deny entry, locked the doors, and refused communication. EMS reported that the resident was left outside for an extended period, during which she was unable to access restroom facilities and soiled herself. Multiple attempts by EMS, police, and hospital staff to resolve the situation were unsuccessful, and the resident was ultimately transported back to the hospital. Interviews with the DON, LPN, and Administrator revealed a lack of coordination and communication regarding the resident's status, medication management, and the facility's responsibilities for a respite hospice patient. Staff expressed fear and uncertainty about accepting the resident back, and there was confusion about whether the resident was still under the facility's care. The DON acknowledged that no assessment was performed upon the resident's return, and the Medical Director was not involved in determining a safe discharge. The incident resulted in a prolonged delay and failure to ensure a safe and appropriate transfer or readmission for the resident.