In Case Involving Resident-to-Resident Attack, DAB Upholds Nearly $700,000 in Penalties

November 1, 2019 | Aging Services Risk, Quality, & Safety Guidance

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After a nursing home resident who was admitted after a psychiatric hospitalization attacked his roommate, the U.S. Department of Health and Human Services' Departmental Appeals Board (DAB) upheld nearly $700,000 in penalties in a case against the facility. In so ruling, the DAB affirmed an administrative law judge decision upholding deficiency citations and penalties issued by the Centers for Medicare and Medicaid Services (CMS).

The resident had dementia, depression, and other behavioral concerns but was physically strong. He had been living in an assisted-living facility, then spent time in a geriatric psychiatric hospital unit after he experienced behavioral issues. Before the nursing home accepted transfer from the hospital, the facility and the psychiatric unit communicated by phone and in writing several times. An admissions representative from a sister facility—who had a marketing background and was not a nurse—skimmed some of the medical notes but missed notations about the resident's aggressive behavior toward others. The roommate had severe cognitive impairment, was partially paralyzed and...

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