Failure to Properly Identify Discharge Location During Immediate Discharge
Penalty
Summary
The facility failed to follow proper immediate discharge procedures for a resident who exhibited increased aggressive behaviors, including multiple physical assaults on staff. After a series of incidents involving physical aggression, law enforcement intervention, and psychiatric evaluation, the resident was sent to a hospital. The facility then determined it could not meet the resident's needs and issued an immediate discharge notice while the resident was at the hospital. However, the discharge notice identified the psychiatric hospital as the discharge location, which did not meet regulatory requirements for specifying an appropriate discharge location. The facility's policy required that, in cases of emergency transfer and subsequent discharge, the discharge location must be properly identified and the resident's status must be evaluated based on their condition at the time of transfer. Despite this, the facility did not amend the immediate discharge notice to reflect an appropriate discharge location after being informed of the error. The discharge letter was also improperly dated, and there was no documentation explaining why the resident was taken into custody on one of the dates in question. The resident, who had a guardian, remained in the hospital pending a hearing after the discharge was appealed. The facility had attempted to find an alternative placement for the resident for several months but was unsuccessful due to the resident's aggressive behaviors. The failure to properly identify a discharge location and to amend the discharge notice as required constituted the deficiency cited in the report.