Failure to Readmit Hospitalized Resident Without Valid Clinical Justification
Penalty
Summary
The deficiency involves the facility’s failure to allow a hospitalized resident to return after an acute care stay, despite having previously indicated an expectation of return and lacking a documented clinical reason for denial. The resident had been admitted with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, cognitive communication deficit, and type 2 diabetes with hyperglycemia, and had a physician order for a vegetarian diet that was later changed to a regular diet with vegetarian options such as cheese and peanut butter. The facility issued a transfer notice stating that the resident had transferred to the hospital and that her return was expected, and that no further action was required unless she wished to appeal the transfer. The facility assessment and policies indicated that the facility provides person-centered care and accommodates religious, cultural, and ethnic dietary needs and restrictions. During the resident’s hospitalization, the hospital case manager documented that the facility indicated it was unable to take the resident back, which required the case manager to work with the resident and family to find another SNF. The resident’s family member reported that the facility refused readmission at the last moment, causing the resident to remain in the hospital an extra day and creating stress and anxiety as the family scrambled to locate another facility. The family member stated that the facility was unhappy with them because they were vocal and advocating for the resident’s needs and preferences, including dietary concerns. Interviews with facility staff revealed inconsistent and unsupported reasons for the denial of readmission. The Admissions Director Assistant stated the resident was denied return due to the resident’s diet and the family’s dissatisfaction with how the facility accommodated the diet, and later referenced unspecified “clinical accommodations” and “limitations” that could not be defined or recalled. The DON stated that clinical concerns are directed to him and that the family’s advocacy regarding the resident’s daily schedule and therapy preferences made planning difficult, but acknowledged that this did not interfere with the resident’s plan of care or ordered services. The DON further stated the denial was categorized as a clinical services issue because the family demanded the resident’s preferences be followed. The facility physician, however, stated there was no medical reason the resident could not be readmitted, including no diet-related reason, and the resident’s transfer documentation and orders did not identify special dietary instructions that the facility could not meet, in contrast to the facility’s stated capacity to accommodate individualized and cultural dietary needs.
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.