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Dismissal Criteria Form (to be completed upon


It is the policy of this facility to discharge residents if or when the service

needs of the individual cannot be met by this facility. The facility reserves
the right to make the final decision as to the ability of the facility to meet a
specific residents needs. The following list of reasons for discharge is not
inclusive and shall be based on the communitys assessment, evaluation
and observations

The resident fails to follow the rules of the
community The resident fails to pay rent and
other fees
The resident interferes with the rights of other
tenants. The resident's service needs cannot
be met in the facility
The presence of the resident threatens the health or safety of other
residents, him/her self, or facility staf

Activities of Daily Living

Resident is unable to transfer him/herself with cueing or requires more than
person Resident requires supervision of meal
choices Resident is unable to eat without
physical assistance
Resident refuses or does not have incontinence control products when
Resident is unable to perform own incontinent care independently or with the
assistance of one person
The Resident has uncontrollable bowel incontinence

Behavioral Issues
Resident is not cooperative in the completion of the Activities of Daily Living
with cueing or assistance (agitated, aggressive, depressed, disturbed sleep,
hallucinations/delusion, impaired judgment, altered afect or behavioral,
resisting care) with staf, visitors or other residents.
Resident exhibits behaviors that may endanger him/herself or
others Violation of other residents rights
Exit seeking behaviors and elopement
Unstable and Unpredictable Health Conditions
Emergency conditions shall result in activation of
Emergency Services Conditions including but not
limited to:
Uncontrolled diabetes related conditions, exacerbations of COPD or
CHF, pressure ulcers, unmanaged or uncontrolled psychiatric
Non compliance with prescribed treatment, diet restrictions, and services
listed on the Individualized Service PlanAny unstable or unpredictable health
Refusing to secure nursing assistance from Home Health Agencies, Hospice,
private care agencies if needed and /or ordered

I understand the above criteria: Date:

(Residents Signature)

Dismissal Criteria Form Updated October 2,