Failure to Follow Transfer/Discharge Policy and Court Order for Resident Readmission
Penalty
Summary
The facility failed to follow its transfer and discharge policy and procedure for a resident who was admitted with multiple complex medical conditions, including cervical spine fusion, functional quadriplegia, inflammatory spondylopathy, chronic pain syndrome, and cervical spinal stenosis. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite a court order requiring the facility to readmit the resident after a hospitalization, the facility did not comply and refused readmission. The facility did not provide the required written notice to the resident regarding the transfer or discharge, nor did it document a legally permissible reason for the discharge in the medical record. The facility also failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals. Interviews with facility staff revealed that although preparations were made for the resident's return, concerns about the resident's behavior led to a decision not to readmit, despite the court order and the resident's expressed preference to return. Documentation from the hospital indicated that the resident was ultimately discharged to another skilled nursing facility after the family was unable to provide care at home. The facility's own policy required that residents be permitted to return after hospitalization unless a proper discharge process was followed, including timely notice and coordination with the resident and their representative. In this case, the facility did not meet these requirements, resulting in the resident being transferred without proper notice or planning.