Failure to Provide Required Written Discharge Notice After Emergent Transfer
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of discharge to a resident and the resident’s representative after an emergent, unplanned discharge. The resident was an elderly male with unspecified dementia and anxiety, admitted in early February and discharged in January to an acute care hospital. His admission MDS showed a BIMS score of 06, indicating severely impaired cognition, and documented behavioral symptoms including physical aggression toward others, rejection of care, and wandering. The MDS also reflected that his overall goal was discharge to the community and that discharge planning was not actively occurring at the time of submission. On the day of discharge, progress notes documented escalating behavioral issues. Nursing notes described the resident becoming increasingly agitated despite staff attempts at redirection and reassurance, physically assaulting a caregiver by punching them in the face, and later being found in bed with his roommate with a pillow and lying on top of the roommate. The resident was then removed to a common area where he flipped a coffee table, attempted to throw a lamp through a window, and began banging on the window. He was sent to a local hospital emergency department via ambulance and police involvement. A physician progress note documented severe agitation, refusal of medications, attempts to leave the facility, and aggressive behaviors such as hitting, biting, kicking, and attempting to head-butt staff, leading the physician to order transfer to the ER and later to state that the facility was unable to accept the resident back until psychiatric evaluation and a period of stability. Interviews with the DON and the LSW confirmed that no written notice of discharge was provided to the resident or his representative following this unplanned discharge. The DON stated that due to the nature of the behaviors, she instructed staff to transfer the resident to the emergency department and to inform the hospital that the resident could not return for safety reasons, and acknowledged that the resident had likely not been given written notice of discharge because the LSW was out of town and the situation was unusual. The LSW stated she was out of town during the resident’s entire admission, was unaware of his admission and discharge, and confirmed that the resident had not been given written notice of discharge. The facility’s transfer and discharge policy required that, in exceptional cases where health or safety is endangered, notice must be provided to the resident, the resident’s representative if appropriate, and the LTC Ombudsman as soon as practicable before transfer or discharge, which did not occur in this case.
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