Failure to Obtain Required Physician Documentation for Facility-Initiated Behavioral Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a facility-initiated transfer and subsequent non-readmission were properly documented in the resident’s medical record and supported by required physician documentation. A male resident with traumatic brain injury, schizophrenia, and a history of methamphetamine use was admitted with noted behavioral issues, including verbal aggression and other disruptive behaviors as documented on his admission MDS and care plan. Over the course of the weekend following admission, multiple staff documented that the resident was verbally aggressive, yelling, cursing, threatening to beat people up if he could not smoke when he wanted, slamming his hand on objects, and throwing or pushing items. Other residents and their families reported feeling scared and uncomfortable, and staff described having to keep residents in their rooms due to concern about the resident’s behavior. In response to these behaviors, the Administrator directed the LBSW to seek admission for the resident to a behavioral health hospital. The LBSW contacted the behavioral hospital, provided required information, obtained acceptance, and then went to the county courthouse to secure Emergency Detention forms signed by a judge. A county officer transported the resident to the behavioral health hospital with the emergency detention paperwork and other documents. The facility’s progress notes describe this process, but review of the resident’s medical record showed no physician order related to the resident’s discharge, no discharge assessment or summary signed by a physician, and no discharge summary or discharge order signed by a physician for the period reviewed. The facility’s own transfer/discharge policy required that when a resident is transferred or discharged because the safety of individuals in the facility is endangered due to the resident’s clinical or behavioral status, the basis for the transfer or discharge must be documented in the clinical record by a physician. The attending MD later stated she had not seen the resident in person because he was only in the facility over one weekend before being sent to the behavioral health hospital, but she had reviewed the notes and believed he was a danger to other residents. She also stated she routinely signed discharge summaries and would have signed one for this resident if she had been asked, indicating that no such request or process occurred. The Administrator and DON both acknowledged in interviews that they were still learning their roles and were unaware of all documentation requirements, with the Administrator specifically stating he did not know a physician signature was required on the documentation explaining the basis for the emergency discharge. As a result, the resident’s record lacked the required physician documentation of the basis for the transfer/discharge under the regulatory criteria, and the facility failed to ensure that the transfer/discharge was fully documented in accordance with federal requirements and its own policy. After the resident’s transfer to the behavioral health hospital, the Administrator reported that the behavioral health hospital later contacted the facility stating the resident was ready for discharge, but the clinical paperwork still reflected similar behaviors, and the facility decided not to readmit him. The Administrator stated he contacted the ombudsman, obtained a list of potentially more suitable facilities, and attempted to reach the resident’s family member (FM) to obtain permission to send referral paperwork to an alternate facility, but the FM did not return his calls. The Administrator then learned from the behavioral health hospital that the family chose to care for the resident in the community, and he stopped working on placement. Throughout this sequence, there remained no physician-signed documentation in the resident’s medical record establishing the basis for the facility-initiated discharge decision as required by regulation and facility policy, which constituted the cited deficiency.
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