Failure to Document Unmet Needs When Declining Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to document specific unmet needs and attempts to meet those needs when declining to readmit a resident following an acute care hospitalization. The resident had diagnoses including acute respiratory failure with hypoxia, C1–C4 complete quadriplegia, and ventilator dependence, and required tracheostomy care, ventilator services, G-tube feeding, pain management, and wound care for a stage 4 pressure injury with a wound vac. The resident was transferred from the facility to an acute care hospital for surgical evaluation and infectious disease consultation related to a right hip/buttock wound. The clinical record at the facility did not contain documentation that the resident returned, nor did it identify any specific needs that the facility could not meet that would prevent readmission. Hospital discharge documentation later showed that the resident’s decubitus ulcers had been evaluated by plastic surgery, no surgical intervention was recommended, the wounds were considered stable with no change to pre-admission management, and IV pain medication had been discontinued in preparation for discharge, with pain status returned to pre-admission levels. Email communications among the Administrator, facility staff, and the Ombudsman showed that the facility initially indicated it would hold the resident’s bed and that the resident would need to be clinically stable prior to return. Subsequent emails documented that the facility expressed concerns that the resident’s condition, including pain medication regimen and wound status, appeared different from when the resident was transferred out, and that there was concern the resident might quickly require a return to acute care. The Administrator and DON later confirmed that decisions about readmission were made by a team and typically documented via email, and that the facility regularly provided wound care and pain management, including a process requiring residents to be off IV pain medication for at least 24 hours prior to admission or readmission. The DON recalled that the facility declined readmission due to perceived worsening wounds and a belief that the resident needed LTACH-level wound care and IV pain management, while acknowledging that hospital records indicated the resident’s wounds were stable and IV pain medication had been stopped. Both the Administrator and DON were unsure whether any documentation existed specifying the resident’s needs that could not be met, attempts to meet those needs, or communication of those needs to the hospital at the time of referral for readmission, and no such documentation was produced during the survey. The facility also lacked a policy regarding permitting a resident to return following hospitalization, despite an admission agreement that addressed transfer, discharge, and bed-hold rights.
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