On June 29, 2010, the Indiana Court of Appeals issued a not-for-publication opinion in Billy Dix v. Indiana State Department of Health and Magnolia Health Systems XVII, LLC.  The case illustrates the importance of providing substantial evidence to the Indiana State Department of Health (ISDH) when a nursing facility plans to discharge a resident because the resident's needs cannot be met by the facility under 410 Ind. Adm. Code. Sec. 16.2-3.1-12(a)(4).

Background

Billy Dix entered Willow Crossing, in Columbus, Indiana, as a quadriplegic in August 2007.  Mr. Dix required extensive care from the staff, as he relied on them to perform activities of daily living, including repositioning him every two hours.  Mr. Dix was very particular about the methods and manner the staff used to attend to his care and needs.  The staff was rarely able to perform the tasks and services to his satisfaction.  He regularly voiced his displeasure with his care by badgering the staff and using vulgar language. 

In October 2008, the facility initiated steps to involuntarily discharge him because the facility felt it could no longer meet his needs under 410 Ind. Adm. Code. Sec. 16.2-3.1-12(a)(4).  Mr. Dix appealed the involuntary discharge.  The ISDH hearing officer held a hearing in Mr. Dix's private room at the nursing facility and issued a decision allowing the involuntary discharge.  Mr. Dix appealed the decision.  The hearing officer's decision was affirmed by the Administrative Law Judge, the ISDH's Appeals Panel, and the trial court.  Mr. Dix appealed each decision along the way.

Informal Hearing does not Violate Due Process

Due to a health issue, the ISDH appeals hearing was held in Mr. Dix's room at the nursing facility and was somewhat informal.  Mr. Dix argued that the ISDH appeals hearing violated his due process rights.  He argued that he could not see all of the witnesses and that there was no clear beginning or end to the testimony at the ISDH appeals hearing.  The Appeals Court reviewed the record of the ISDH appeals hearing and found that Mr. Dix, and the local ombudsman assisting him, offered evidence, argued their position, confronted witnesses and offered closing statements.  The Indiana Appeals Court held that, while the hearing was exceedingly informal, due process was given during the ISDH appeals hearing. 

Facility's Documentation Substantiates Grounds for Involuntary Discharge

Mr. Dix also contended that the nursing facility failed to establish by a preponderance of the evidence that it could not meet his needs.  Under 410 Ind. Adm. Code 16.2-3.1-12(a)(4), a resident has a presumptive right to remain in a nursing facility unless one of the six limited criteria is established by a preponderance of the evidence to ISDH.  

The Appeals Court found that the nursing facility made every effort to work with Mr. Dix, including an incredible amount of extra and specialized training, but it was still unable to meet his needs.   The nursing facility documented examples of Mr. Dix's extreme dissatisfaction with the care provided and Mr. Dix's indication that there was no one at the nursing facility who could give him consistently proper care.  The day prior to the nursing facility's notice of discharge, Mr. Dix's physician documented the clinical records with a statement that Mr. Dix's discharge was necessary for his welfare, as his continuity of care needs could not be met by the nursing facility, as evidenced by Mr. Dix's statement.
 
The Appeals Court held that while the facility was equipped to meet Mr. Dix's medical and living requirements, the resident's demands of care proved unattainable by the staff and resulted in his extreme dissatisfaction.  The Appeals Court saw that the physician's report, the resident's statements, and the documentation of the facility's efforts supported the ISDH's conclusion that the facility was unable to meet his needs. 

Practical Takeaways

• Even if the appeals hearing on an involuntary discharge is informal, nursing facilities should make sure that they present all of the testimony and records they have to substantiate their grounds for discharge.
• Before initiating an involuntary discharge for failure to meet a resident's needs, a nursing facility should collect and document the facility's efforts, as well as statements from the physician and resident to demonstrate that those needs are not being met.