F0627

D

Failure to Readmit Hospitalized Resident After Transfer for Behavioral Concerns

Salisbury, North Carolina Survey Completed on 01-02-2026

Penalty

Fine: $20,385

Summary

The deficiency involves the facility’s failure to allow a resident to return following a hospital transfer, despite the transfer/discharge being identified as a discharge-return-anticipated. The resident had diagnoses of alcohol abuse and dementia and was assessed as severely cognitively impaired. A quarterly MDS and a discharge-return-anticipated MDS were completed, and on the same day the social worker documented that the guardian was notified the resident was being issued a 30‑day discharge notice for behaviors the facility stated it could not manage, and that the facility was going to proceed with involuntary committal because it could no longer keep the resident safe. Later that day, a nurse documented that the resident was transferred to the hospital for evaluation after aggressive behavior and extreme exit seeking, and that the resident was calm at the time of discharge. A written Nursing Home Notice of Transfer/Discharge, signed by the administrator, cited endangerment to the safety of individuals in the facility due to the resident’s clinical or behavioral status and indicated the guardian was notified of the transfer.

Interviews and record review showed that the resident had previously climbed onto the facility roof and later attempted again by stacking lawn furniture in the courtyard. The social worker reported that the guardian was told the facility could no longer handle the resident’s behaviors and that he was sent to the hospital after a second roof attempt. The guardian stated she had not been informed of the first roof incident, but had been told previously that the resident was pushing other residents in wheelchairs and that the facility wanted to move him to a secured dementia unit, which she refused. The guardian reported being told by the social worker that the resident was sent to the hospital because he was suicidal and that the facility refused to accept him back on the grounds that they were unable to keep him from harming himself. The resident later told the guardian from the hospital that he was not suicidal and just wanted to leave the facility.

Nursing and administrative staff interviews further described the events leading to the transfer and the refusal to readmit. A nurse stated the resident had always walked around the facility and had not attempted to leave until he was told he was being moved to the secured dementia unit, after which he became more agitated and was perceived as potentially harmful to others, though not suicidal. The nurse stated the resident needed one‑to‑one supervision or placement on the secured dementia unit, but the facility did not have staff for one‑to‑one care. The former DON stated the resident was exit seeking and became more aggressive after the initial roof incident, and that the facility refused to take him back because he would not agree to placement on the secured dementia unit or to wearing an electronic wander guard bracelet. The hospital discharge summary documented that the resident was medically stable, did not meet criteria for inpatient psychiatric admission, and that his hospitalization was prolonged because his original facility declined his return, with eventual placement arranged at another facility with a secured dementia unit.