Failure to Ensure Safe Discharge and Right to Appeal
Penalty
Summary
The facility failed to ensure that a resident was not discharged when exercising the right to appeal a discharge notice, and did not provide for a safe and appropriate discharge environment. The resident, who was cognitively intact and had significant medical needs including vertebra osteomyelitis, stage 3 and 4 pressure ulcers, neuromuscular bladder dysfunction, paraplegia, protein-calorie malnutrition, cellulitis, and sepsis, was issued an immediate discharge notice following allegations of making threats toward staff. The discharge notice did not specify an address for discharge, and the resident was served the notice in the presence of police officers, with a no trespass order also issued. The resident declined offers for a hotel stay and hospital transport, stating he could not care for himself and needed ongoing care and services. Despite this, the facility proceeded with the discharge, and the resident reported having nowhere to go, ultimately sleeping in his truck and not receiving necessary wound care, meals, or ADL assistance after discharge. Interviews with facility staff revealed inconsistencies and lack of clarity regarding the alleged threats, with some staff unable to recall details or confirm the nature of the threats. Documentation and incident logs did not consistently reflect the reported behavioral incidents leading to the discharge. The facility did not implement additional interventions such as 1:1 supervision or behavioral services prior to discharge, and there was no evidence of a completed discharge planning review or confirmation of a safe discharge location. The resident's hospice provider was notified, but there was no confirmation that hospice services continued after discharge or that the resident had access to necessary care and supplies. The facility also failed to allow the resident to remain in the facility during the appeal process, as required, citing immediate jeopardy due to the alleged threats. The resident and some staff disputed the severity and veracity of the threats, and the resident denied making specific threats to shoot staff. The facility's actions resulted in the resident being left without a safe discharge plan or continued care, despite his complex medical needs and dependence on staff for assistance with activities of daily living and wound care.