On February 1, 2019, Alice Manor, a nursing home in Fowler, discharged a 54 year old male resident with diabetes, dysphagia, schizophrenia, and memory loss to an unlicensed room and board home. The discharge was done suddenly and haphazardly, with no written notice to the resident, no evidence of improvement, no discharge planning, and no assessment of the resident’s or room and board home’s ability to administer insulin or manage the resident’s incontinence, hygiene needs, and puree diet. When asked what vetting the facility did to ensure the resident would be appropriately cared for, the Director of Nursing said “we didn’t check anything.” The room and board operator stated the facility was not truthful about the resident’s needs and that less than 24 hours after his transfer he had to be hospitalized. The facility was cited for failing to ensure a safe discharge process and for placing the resident at great risk in an unlicensed facility unable to meet his needs.

Download the pdf of this citation HERE.
Violation of the Month Archive