Failure to Ensure Safe and Orderly Discharge for Resident Refused Readmission
Penalty
Summary
The facility failed to ensure a safe, orderly, and properly documented discharge for a resident who was ultimately refused readmission after a hospital stay. The resident, who had multiple medical conditions including anxiety disorder, paralysis, diabetes, amputation, cognitive decline, and housing instability, was initially given a 30-day discharge notice for nonpayment. Despite the notice and a subsequent eviction petition, the resident remained at the facility until he was sent to the hospital for shortness of breath. Upon stabilization, the hospital attempted to return the resident, but the facility refused to accept him back, citing the prior eviction for nonpayment. There was no evidence in the nursing notes or social services documentation of any discharge planning or actions to ensure the resident's needs and preferences were met prior to his hospital transfer and subsequent discharge. The facility did not coordinate with the hospital or other agencies to secure a safe and appropriate placement for the resident after his hospital stay. The resident remained in the hospital for over 30 days while the hospital social worker made numerous unsuccessful placement referrals, as the facility continued to refuse readmission. Interviews with facility staff revealed a lack of awareness and involvement in the discharge process, with the current administration attributing the actions to previous ownership. The Ombudsman was not notified or involved in the discharge, and there was no evidence of adherence to the facility's own resident rights policy, which requires equal access to care and proper discharge procedures regardless of payment source.