March, 2020
A 61 year old male wheelchair-bound resident with blood clots and a colostomy was found dead in an unlicensed care facility on 8/12/19 after being discharged by the nursing facility on 7/10/19. The resident’s death was discovered while the nursing facility was being investigated for discharging residents “because it only wanted Medicare residents.” The deceased former resident had extensive care needs, including colostomy care and medication administration that was dependent on his blood pressure readings. The resident’s physician wrote an order to discharge the resident to an assisted living facility and discontinued the resident’s blood thinner despite his history of blood clots. The resident was sent to the unlicensed facility, despite its complete inability to provide care, with four colostomy bags and no discharge plan. On or about 7/26/19, the resident was sent back to the nursing facility because he had run out of colostomy bags. The facility called the police on the resident and a police officer transported him back to the unlicensed facility. The facility’s staff later admitted that the resident’s discharge was botched. The former social services designee stated “the facility had a pattern of discharging residents who were not ready for discharge in order to admit new residents.” An internal facility email indicated the nursing facility made payments to the unlicensed facility before sending residents there. The nursing facility was cited for discharging the resident without justification, a plan, or an appropriate placement.
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