T22 DIV5 CH3 ART5-72527(a)(6) Patients' Rights
(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:
(6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record.
Patients have the right to be discharged only for medical reasons, or the patient's welfare, or that of other patients or for nonpayment for his stay and to be given reasonable advance notice to ensure safe and orderly discharge. Such actions shall be documented in the patient's health record.
The facility violated the aforementioned regulation by failing to follow the policy and procedure for transfer and discharge, and permit Resident 1 to remain in the facility, and not discharge him on 8/16/12 at 10:35 p.m. Resident 1 was involuntarily discharged to the street in front of the facility without discharge planning for his shelter, transportation, medication, wound care supplies, meals, or his ability to obtain assistance.
Review on 8/20/12, of Resident 1's clinical record, showed he was admitted to the facility on 4/26/12. Diagnoses included above the knee amputations on both legs and phantom limb syndrome (pain experienced as if the missing limbs were still there), lumbago (painful condition of the lower back), insulin dependent diabetes mellitus, and four Stage II pressure ulcers (shallow open ulcers). Resident 1 depended on a staff member for bathing and toilet use. Resident 1 was often incontinent of bowel and had a catheter in his bladder for urine drainage and collection. Resident 1 used a battery equipped wheel chair which required recharging from an electrical outlet.
In an interview at 3:45 p.m., on 8/17/12, Resident 1, who is currently living in a Board and Care home, stated that on 8/15/12, he was absent without leave from the facility for approximately one hour, from 9 p.m., until 10 p.m. When he returned to the facility, he was informed that he was being discharged. Resident 1 stated that he told the staff that he did not want to go. Resident 1 also stated that he was escorted from the building at 10:35 p.m., on 8/15/12 by the Sheriffs department and was left on the street by the facility sign. He stated that he remained there overnight, until the following evening, because he didn't know where to go.
Review of the Physician orders showed a telephone order dated 8/15/12, at 9:30 p.m. The order reflected, "Resident discharge himself AMA AFA May not release with meds Go to ER if needs help". (against medical and facility advice)
In a written declaration, dated 8/23/12, the Resident's daughter, (RP) stated that she received a phone call from the facility at 12:48 a.m., on 8/16/12. The caller told RP that there was an incident at the facility, the police were called, Resident 1 was taken away in an ambulance, and he would not be allowed to return. Later in the day, RP tried to locate Resident 1. She called the facility, and Resident 1 was not there. She called the Sheriffs Department, and was told that Resident 1 was at the facility. The sheriff told RP that Resident 1 was not taken away in an ambulance.
RP found Resident 1 around 5 p.m., on 8/16/12, beside the facility's sign. He was slumped over in his wheelchair. Resident 1 was drowsy and extremely puffy in the face, arms and hands and his catheter bag was very full. Resident 1 told her he was in severe pain. RP called 911. Paramedics arrived at 8:38p.m., on 8/16/12. Resident 1 was on the street for nearly 23 hours before transportation to the hospital by the paramedics.
The quarterly Minimum Data Set (MDS - resident assessment) dated 7/3/12, did not show current discharge planning.
A care plan, titled, "Community Discharge Potential", dated 7/9/12, reflected that staff were to, "Coordinate discharge plans with the resident and responsible party," and to, "Assist in community referral for continued care."
There was no documentation in Resident 1's clinical record to show that Resident 1 or his Responsible Party were given an opportunity to participate in creating a discharge plan addressing his needs for housing, activities of daily living (ADL) care, food, medications, wound care, or safety. There was no documentation in Resident 1's clinical record to show 30 day notice was given.
During an interview at approximately 3 p.m., on 9/18/12, the Director of Nursing Services (DNS) stated that the Interdisciplinary Team (IDT) did not assess the post discharge care needs of Resident 1 with the participation of the resident and his Responsible Party (RP).
In an interview with RN 2 at 4:11 p.m., on 9/21/12, she stated Resident 1 was escorted to the street at 10:35 p.m., on 8/15/12 without a destination for shelter or a meal plan, transportation, medication (antibiotics for an infection, insulin to reduce blood sugars, pain medication for severe pain) wound care supplies, or a means of contacting anyone for help. RN 2 stated that if Resident 1 did not have a cell phone, he could go to a phone booth to make calls.
Review on 8/20/12, of facility policy dated 12/18/02, entitled, "Transfer and Discharge" showed: "Procedure:
4. At least 30 days prior to transfer or discharge, notify the resident and if known, the
family member ... of the transfer and the reasons for the move.
a. Provide the information in writing ...
b. Explain the resident's right to appeal the transfer/discharge.
c. Provide the name, address, and phone number of:
- the State long term care ombudsman,
- the agency responsible for advocating for individuals [with special needs]
5. Provide preparation and orientation to the resident to ensure safe and orderly
transfer/discharge from the facility ...
- Informing the resident where [s/he] is going;
- taking steps to assure safe transportation;
- involving the resident and family in selecting the new residence ... "
During an interview at approximately 4:30p.m., on 9/25/12 the Director of Nursing Services (DNS) stated that when Resident 1 was being escorted from the facility, on 8/15/12, RN 1 gave him a Post Discharge Plan of Care. The document was not developed with the participation of Resident 1 and the family member as required. The form reflected that Resident 1 had the following nursing needs: wound care; suprapubic catheter care (catheter inserted directly into the bladder through a small hole in the abdomen), medication, and pain management. The document lacked instructions for the current antibiotic prescription; for checking blood sugars, drawing up and giving insulin, catheter care, where to buy wound care and catheter supplies, and where to get his medications. The document did not include information about how to arrange for transportation, meals, a method of recharging the wheelchair battery, and resources for areas in which Resident 1 was dependent on staff, such as care in toileting and bathing. In a space titled, "Procedures you should do", a facility employee wrote, "Go to ER if needs help". The spaces for a pharmacy name and phone number, and community resources, were blank.
Therefore the facility failed to:
1. Give reasonable advance notice to ensure safe and orderly discharge.
2. Permit Resident 1 to remain in the facility and not to discharge him, when on 8/15/12, he was involuntarily discharged to the street in front of the facility.
3. Develop a discharge plan of care with the participation of Resident 1 and a family member designed to help Resident 1 adjust to a new home.
4. Issue a written discharge notice containing the required information to the resident and a family member at least 30 days prior to discharging Resident 1.
The above violations had a direct or immediate relationship to the health, safety or security of the patient.