Failure to Honor Resident's Discharge Rights and Follow Policy
Penalty
Summary
The facility failed to honor a resident's right to self-determination and to follow its own policies regarding discharge and decision-making when no power of attorney (POA) or guardianship was in place. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including dementia and major depressive disorder, was his own responsible party with no legal documentation granting decision-making authority to any family member. Despite this, the facility did not allow the resident to discharge with a family member (FM A) as he wished, and instead followed the wishes of another family member (FM B) who had no legal authority. On the day of the incident, FM A arrived at the facility to facilitate the resident's discharge, which the resident verbally supported. Facility staff, including the interim administrator and DON, denied the discharge, citing concerns about FM A's behavior and vehicle condition, as well as unsubstantiated allegations of past mistreatment presented by FM B. The facility then barred FM A from the property and from having contact with the resident, despite the lack of any substantiated evidence or legal documentation restricting her involvement. The resident expressed a desire to leave with FM A and reported no safety concerns about living with her. Interviews with facility staff, the ombudsman, and both family members confirmed that there was no active POA or guardianship, and that the facility's actions were based on unsubstantiated allegations and the preferences of FM B rather than the resident's expressed wishes or established policy. The facility's own discharge policy required informing the resident and family of risks, notifying the physician, and documenting the process, none of which were followed in this case. The failure to adhere to policy and to respect the resident's rights resulted in the resident being denied the ability to discharge as he wished.