Failure to Ensure Safe Discharge and Thorough Investigation Following Alleged Threats
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident with complex medical needs. The resident, who was cognitively intact and had significant medical diagnoses including vertebra osteomyelitis, stage 3 and 4 pressure ulcers, neuromuscular bladder dysfunction, paraplegia, protein-calorie malnutrition, cellulitis, and sepsis, was subject to an immediate discharge following allegations of making credible threats of violence toward staff, including a threat to shoot the administrator. The discharge process was initiated without a thorough investigation into the validity of the witness statements regarding the alleged threats. Documentation and interviews revealed inconsistencies and a lack of clarity about the nature and timing of the threats, as well as insufficient documentation in the resident's progress notes and incident logs related to the alleged incidents. The facility did not take immediate action to ensure the safety of all residents when the alleged credible threat was reported. There was a delay in notifying law enforcement, and the resident was not placed on 1:1 supervision or provided with other interventions during the period between the alleged threat and the discharge. Staff interviews indicated confusion about the process for handling such threats, and there was no clear evidence that behavioral or psychiatric services were offered or that the resident's care plan was updated to address the situation. The discharge notice provided to the resident did not include an address for discharge, and alternative placement options were limited to a hotel stay, which the resident declined due to inability to self-care. Following the immediate discharge, the resident, who required assistance with activities of daily living and wound care, was left without a safe and proper discharge plan. The resident reported having nowhere to go, ultimately sleeping in his truck and not receiving necessary care, meals, or wound care supplies. Facility leadership and staff were unable to confirm the resident's whereabouts or continuity of care post-discharge. The discharge planning review was incomplete, and there was no evidence of follow-up or due diligence to ensure the resident's safety and ongoing care after leaving the facility.