Failure to Provide Resident‑Centered Discharge Planning and Readmission for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an appropriate, resident‑centered discharge planning process and safe transition for a resident with known suicidal ideation and dementia. The resident had diagnoses including cognitive communication deficit and unspecified dementia with agitation, and an MDS BIMS score of 4/15 indicating severe cognitive impairment. The care plan documented a language barrier due to the resident’s primary language being Russian and identified suicidal ideation related to dementia, with interventions for close monitoring and suicide precautions. On one date, an LVN documented that the resident was found around 9:30 a.m. with a string used to turn the room light on/off wrapped tightly around her neck; the nurse intervened, removed the string, and notified the MD and responsible party. Later that day, progress notes indicated that police arrived around 4:00 p.m., attempted to calm the resident, and then called an ambulance, which transported the resident to an acute care hospital at approximately 4:20 p.m. At the acute care hospital, the MSW reported that the resident was considered ready for transport back to the facility the following day, but when the MSW contacted the facility’s DON, the DON declined to accept the resident back, citing the resident’s high risk for self‑harm and the facility’s lack of trained staff to meet the resident’s needs. The MSW also stated this was not the first time the facility had refused to readmit its residents. Hospital progress notes documented that the DON stated the facility would not accept the resident back due to high risk of self‑harm. In a later interview, the DON stated the facility did not accept the resident back because staff could not adequately communicate with the resident due to the language barrier and that the resident had not shown self‑harm behaviors prior to the incident, despite the care plan having identified both the language barrier and suicidal ideation months earlier. This refusal to readmit resulted in an extended acute care hospital stay and placed the resident at risk for an unsafe and unplanned transition.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.