Failure to Provide Notice and Safe Discharge Planning for Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and properly planned discharge for a resident with dementia, type 2 diabetes mellitus, and encephalopathy whose wife was the responsible party. The resident was admitted on 07/11/25 and, on 11/29/25, received a pink slip due to physical aggression with staff and was transported by facility bus to a psychiatric hospital, with the transfer log indicating an expected return. A physician progress note dated 12/01/25 documented that the resident had spontaneously pushed two residents and physically struck a staff member and stated that an immediate discharge would be appropriate to prevent harm to residents or staff. The facility was aware of the planned immediate discharge from the psychiatric hospital but did not provide documentation that the resident’s representative was notified of an impending involuntary discharge, given written notice, or afforded appeal rights prior to the discharge. On 12/16/25, the facility picked the resident up from the psychiatric hospital and transported him by facility bus to his representative’s home address, despite no documented discharge planning, interdisciplinary evaluation, or assessment of the safety or appropriateness of the discharge location. The representative did not answer the door but communicated with the resident and the former Administrator via doorbell camera, and the Administrator then had the resident transported to a local hospital because the wife would not take him back and he could not return to the facility. The resident’s representative reported she had not been notified in advance that the facility would not accept the resident’s return, was not given the opportunity to appeal the discharge, and was not able to prepare for his discharge. She also stated that frequent transfers between facilities triggered his PTSD and that her responsibility for caring for her elderly mother made her home unsuitable for his care. The facility’s own discharge planning policy required involvement of the resident and/or representative in discharge planning, provision of education and communication prior to discharge, and assurance that the discharge destination met the resident’s health and safety needs and preferences, which was not demonstrated in this case.
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