Failure to Honor Resident’s Request for Discharge and Right to Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination when the resident’s request to be discharged was not granted. The resident was admitted in 11/2025 with diagnoses of essential HTN and Type II DM, and a physician order dated 11/11/25 indicated the resident was capable of understanding rights, responsibilities, and informed consent. On the evening of 1/28/26, the resident told the Social Services Director that he wanted to discharge from the facility. An Alert Note dated 1/29/26 at 12:46 a.m. documented that at approximately 8:30 p.m. on 1/28/26, the resident and a visitor requested an explanation as to why the resident could not leave the facility at that time. The nurse explained that per facility protocol and due to safety concerns, the resident was not cleared to leave and that a discharge care meeting could be arranged during normal business hours, and informed the visitor that leaving would be unsafe and against medical advice. Interviews and record reviews confirmed that, despite the physician’s order deeming the resident responsible for himself, staff did not allow him to discharge and did not offer a release of responsibility form as required by facility policy for discharges without physician approval. The Social Services Director, Assistant DON, and Director of Staff Development each verified that the resident was responsible for himself and had the right to leave the facility, and the Assistant DON confirmed that staff should have offered a release of responsibility form but did not. The nurse on duty stated she told the resident it was late, that nothing could be figured out at night, there was no administrative staff available, and she did not know the procedure or what to do, believing that allowing discharge at night would compromise safety. The resident later stated by telephone that he had wanted to go home at that time but was not allowed to do so and that he was really upset and frustrated. Facility policies on “Discharging a resident without Physician’s Approval” and “Resident’s Rights” indicated that residents requesting discharge without physician approval should be asked to sign a release of responsibility form and that residents have the right to self-determination.
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