Failure to Provide Valid Basis for Declining Readmission and Inadequate Discharge Process
Penalty
Summary
Facility staff failed to provide a valid basis for declining the readmission of a resident following a hospital stay, despite the resident having a paid bed hold and an anticipated return. The resident, who was cognitively intact and had multiple diagnoses including Multiple Sclerosis, Paraplegia, Osteoarthritis, and Congestive Heart Failure, was discharged to the hospital with a return anticipated, as documented in the clinical record and MDS. Upon discharge planning, the hospital communicated that the resident and family wished to return to the facility with hospice services, and coordination between the facility and hospice was requested. However, the facility administrator declined readmission, citing the lack of a universal hospice contract and the resident's new hospice order as reasons, despite the facility's practice of individualized hospice contracts. The administrator confirmed that a discharge notice was only provided at the time of the resident's transfer to the hospital, not after the decision to decline readmission. Facility policy requires documentation supporting the basis for discharge and specific unmet needs, but no further information was provided to the survey team. The surveyor's review found that the facility did not develop or implement an appropriate discharge process for the resident or their representative, and failed to ensure the transfer/discharge met the resident's needs and preferences.