Failure to Provide and Document Bed-Hold Policy and Discharge Notice
Penalty
Summary
A deficiency occurred when the facility failed to provide and document sufficient preparation and orientation to a resident and her family regarding the facility's bed-hold policies during a discharge event. The resident, who had multiple complex medical diagnoses including rheumatoid arthritis, multiple sclerosis, chronic pain, and moderate cognitive impairment, was transferred to the hospital for abdominal pain and related medical interventions. There was no evidence in the medical record of a discharge order, discharge summary, or physician's handwritten progress note detailing the discharge. The resident reported that she was promised she could return to the facility if she ever went to the emergency room, but while hospitalized, she learned from a hospital counselor that the facility would not allow her to return. The facility staff communicated this decision to the resident while she was still in the hospital, citing aggressive behavior and non-compliance with treatment as reasons, but there was no documentation in the facility records to support these claims. The resident was not notified in advance that she would not be allowed to return, and her belongings remained in her room until her family member retrieved them. Interviews with facility staff, including the admission coordinator, DON, ADON, and administrator, revealed inconsistent accounts regarding the reasons for the resident's discharge and lack of documentation of the alleged behaviors. The facility's own transfer and discharge policy requires written notice of bed-hold and readmission policies, documentation of the discharge process, and communication with the resident and family, none of which were found in this case. The required discharge notice, documentation of preparation and orientation, and explanation of appeal rights were not provided to the resident or her family.