The Iowa Department of Inspections and Appeals (DIA) reported that an Iowa nursing home would be fined $20,000 after a resident was inappropriately discharged and left outside for 11 hours overnight. The DIA received an “immediate jeopardy” complaint of neglect on June 27. An investigation completed July 13 found that the events leading to the complaint included six state and three federal code violations.
The surveyor’s report stated that based on clinical record review, resident interview, and staff interviews, the facility failed to provide necessary goods and services to a resident who the facility failed to allow reentry to the building after the resident went outside. A staff member entered the door code for the resident to leave at approximately 5:08 PM on 6/22/22. The resident remained outside in a manual wheelchair across the street from the facility until 4:00 AM on 6/23/22. The resident then called a taxi service and fell into the taxi attempting to self-transfer without his slide board. The taxi service contacted Emergency Medical Services and the resident was transported to the hospital. The facility failed to provide the resident food, transfer assistance, treatments, and medications which included insulin. This failure resulted in an immediate jeopardy.
According to the progress note dated 6/22/22 at 5:08 PM, the resident had attempted to go outside to smoke even though he had been told that he was not able to go outside and smoke. He then became upset and verbally abused staff. He went down the hall and stated that he was leaving. A nurse went up to the resident and said that if he was going to be leaving, he should sign the Against Medical Advice (AMA) papers. He refused to sign. The nurse educated the resident on the importance of signing AMA papers and told him that once he left, he would not be able to come back, and the facility would no longer be responsible. The resident still refused to sign. During medication pass the nurse noted the resident was not in the facility anymore. A staff member had let the resident outside, and he was at the end of the driveway waiting for a ride from a friend.
The Progress Note dated 6/22/2022 at 6:03 PM stated that the resident had left all of his belongings in the facility. The Power of Attorney (POA) was notified that the resident was discharged from the facility. Per the direction of the interim Director of Nursing (DON), the resident was not to be let back in the facility, and the POA would be responsible for collecting the resident’s belongings.
According to interviews with staff and the ombudsman, residents had previously been allowed to go outside and smoke, but on 6/22/22 staff were told in a meeting that residents were no longer allowed to do so. The administrator and DON had abruptly told the residents that the facility was going smoke free and they would no longer be allowed to smoke as of that moment. The code on the door residents would use to go outside had been changed as well. They said no assistance had been offered or prior warning made so residents could have a plan or speak with their medical providers for help regarding abrupt abstinence from smoking.
Issue:
Discharging a resident without providing supporting documentation that the discharge or transfer is based on one of the six allowable reasons, and failure to ensure the discharge is to a safe location, may be considered provision of substandard quality of care, in violation of state and federal regulations. Facilities must also establish policies, in accordance with applicable federal, state, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. Staff and residents should be informed in a timely manner of any changes in smoking policy so they can receive needed assistance such as nicotine replacements. The recently revised F561 Self-Determination states: “If a facility changes its policy to prohibit smoking (including electronic cigarettes), it should allow current residents who smoke to continue smoking in an area that maintains the quality of life for these residents and takes into account non-smoking residents. The smoking area may be an outside area provided that residents remain safe. Residents admitted after the facility changes its policy must be informed of this policy at admission.”
Discussion Points:
- Review policies and procedures regarding admission, transfer, and discharge of residents, including the protocols for AMA discharges. Review your policies and procedures for smoking, smoking areas, and smoking safety. If your facility is smoke-free, ensure your policies include a process for informing new residents of that fact before admission, offering help to residents with smoking cessation, and giving current residents who smoke the option of a safe smoking area with supervision.
- Train staff on proper discharge procedures, smoking safety, and supervision of residents. Document that these trainings occurred and file the signed document in each employee’s individual education file.
- Periodically audit instances where the facility transferred or discharged a resident to ensure compliance with F622 Transfer and Discharge, in the State Operations Manual, Appendix PP. Also periodically audit to ensure that smoking safety measures are being followed, that residents have adequate supervision, and that care plans addressing safe smoking and smoking cessation are current.
