Failure to Document and Prepare for Safe Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate evidence of a proper discharge for one resident who was reviewed for discharge and transfers. The facility's physician did not document the specific needs of the resident that could not be met at the facility, nor the facility's attempts to meet those needs, or the services available at the receiving facility to meet the resident's needs. The resident in question had a history of violent and aggressive behaviors, was on multiple psychiatric medications, and was sent to the hospital for a mental health evaluation. Despite being medically cleared to return to the facility, the facility declined to readmit the resident, citing inability to provide 1:1 supervision and necessary mental health services. Documentation reviewed by the surveyor showed that the facility issued a 30-day discharge notice to the resident's family member, stating the facility could not meet the resident's care needs due to unpredictable and uncontrollable behaviors. The family member expressed distress and safety concerns about the possibility of the resident returning home, as well as financial concerns regarding bed hold payments. Communication between the facility and the hospital was inconsistent, with the hospital social worker not being informed of the discharge notice while the resident was still hospitalized. The facility's documentation included a physician's verbal order to discharge the resident per the guardian's request, but lacked detailed assessment or rationale regarding the resident's needs and the facility's inability to meet them. Interviews with facility staff confirmed that the facility does not admit residents requiring long-term 1:1 supervision due to staffing limitations, and that the resident was requiring such supervision while hospitalized. The facility's DON and NHA indicated that the plan was to reassess the resident, but ultimately the facility decided not to readmit the resident. The surveyor found no documentation from the facility's physician outlining the specific needs that could not be met, the facility's attempts to address those needs, or the services available at the receiving facility, as required for an appropriate and safe discharge.