F0627

D

Failure to Coordinate Safe Discharge and Readmission for Resident With Behavioral Needs

Albuquerque, New Mexico Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to appropriately manage the transfer and discharge of a resident with significant neurological and psychiatric diagnoses, including cerebral infarction, unspecified cerebrovascular disease, dysphagia, severe dementia with behavioral disturbance, generalized anxiety disorder, major depressive disorder, aphasia, and cognitive communication deficits. The resident had a care plan identifying risks for verbal and physical behaviors and elopement, with interventions such as monitoring for aggressive intent, evaluating triggers, providing psych/behavioral health consultation, and using calm redirection. Nursing notes documented that the resident exhibited escalating behavioral symptoms, including verbal abuse and homicidal ideations, leading to calls to local police and transfers to the hospital for evaluation and treatment.

Following an earlier hospital evaluation, the resident was returned to the facility and placed on 1:1 supervision, with documentation that psych providers agreed with this level of supervision and ordered new medications. Progress notes indicated periods where the resident’s mood was pleasant and no unwanted behaviors were observed. However, on a later date, staff documented that despite 1:1 supervision, the resident continued to have verbal and physical aggression toward staff and others, and that her care could not be safely managed at that level of care. That same morning, the resident approached the administrator, DON, and supervising staff, expressed frustration with the ongoing 1:1 supervision, and then hit the administrator and threw a vase of flowers at the activities director, prompting activation of 911 and transfer to the hospital with EMS and police.

The deficiency centers on the facility’s failure to ensure a safe and coordinated discharge and appropriate readmission planning after the resident was sent to the hospital. Nursing documentation shows the resident was discharged from the facility when she left with EMS and police. The guardian reported that after this transfer, the facility would not re‑admit the resident once she was ready for discharge from the hospital, resulting in the resident remaining in the hospital emergency room holding area while the guardian and hospital case managers searched for a safe placement. The social services director stated she did not believe it was a safe discharge and that the administrator decided not to re‑admit the resident. The hospital case manager director reported that when they contacted the facility, they were told the facility had done an immediate eviction and would not allow the resident to return, and that the resident showed no aggressive behavior in the hospital and did not meet criteria for hospital admission, leading to her being held in the emergency room for several days until transfer to an out‑of‑town assisted living facility could be arranged.