Failure to Ensure Safe and Properly Documented Resident Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide and document adequate preparation and orientation for the transfer or discharge of a resident with severe cognitive impairment and multiple psychiatric diagnoses. The resident, who had a legal guardian due to his inability to advocate for himself, was involved in several altercations with other residents, leading the facility to seek alternate placement for his safety. Despite communication with the guardian regarding the need for transfer, the facility did not ensure that the new placement was within the jurisdiction of the resident's registered guardianship program, resulting in the resident being transferred to a location where his guardian had no authority. The facility did not provide or document a written discharge notice to the resident or his guardian, nor did they obtain the guardian's signature on the discharge paperwork indicating the destination facility. Additionally, there was no documentation that the ombudsman was notified of the discharge, and the psychiatric nurse practitioner was not consulted to determine if the resident posed a danger to himself or others. Interviews with facility staff, including the ADON, Administrator, and DON, revealed a lack of clarity regarding responsibility for following discharge procedures and acknowledged that several required steps were not completed according to facility policy. The resident's guardian was informed of the transfer by phone but was not given the opportunity to approve the final placement, as the facility proceeded with the transfer despite being notified that the guardianship program did not cover the new location. The guardian provided a list of acceptable areas, but the facility did not adhere to these guidelines. The psychiatric NP stated that the resident did not exhibit behaviors that could not be managed at the facility and was not a danger to himself or others. The failure to follow proper discharge procedures resulted in the resident being placed in a facility without an authorized representative to advocate for his needs.