Inadequate Discharge Planning and Readmission Issues
Summary
The facility failed to adequately prepare for the discharge of two residents, resulting in unsafe discharges and the inability to readmit one resident post-hospitalization. Resident #4, who was moderately cognitively impaired and required assistance with mobility and activities of daily living, was discharged home without proper support. Upon arrival at home, the resident was unable to care for himself, leading to a return to the hospital the following day. The discharge planning did not adequately consider the resident's needs for assistance, and the facility did not have a focus on discharge planning in the care plan. Resident #5, who had diagnoses including Parkinson's disease and congestive heart failure, was also discharged without proper planning. The resident's Durable Power of Attorney reported not receiving necessary information about insurance, Medicaid resources, or bed hold policies, which led to financial stress and complications in securing Medicaid. The facility attempted to discharge the resident when Medicare coverage ended, despite the resident requiring substantial assistance with ADLs. The facility did not provide a Notice of Medicare Non-Coverage or inform the resident's representative of the right to appeal the discharge decision. The facility's policies on discharge and transfer were not adequately followed, as evidenced by the lack of proper documentation and communication with residents and their representatives. The facility's focus on being a Sub-Acute Rehab (SAR) rather than accommodating long-term care needs contributed to the inadequate discharge planning and failure to readmit residents post-hospitalization. The facility did not have a policy on readmitting residents after hospitalization, and there was a lack of communication regarding bed hold policies and financial responsibilities.
Penalty
A resident with multiple complex medical conditions was discharged while her appeal was still pending, and before all necessary home equipment and support services were in place. The facility proceeded with the discharge after determining the appeal was filed outside the 10-day window, despite having received notice of the scheduled hearing. The resident was left without essential equipment and adequate caregiver arrangements, resulting in dependence on a family member for personal care.
A resident was transferred to the hospital without their comprehensive care plan goals included in the required documentation. Both an RN/Unit Supervisor and an LPN confirmed that care plan goals were not sent with residents during transfers, and this issue was reviewed with the DON.
A resident with schizophrenia and recent elopement attempts was subject to involuntary transfer and discharge procedures initiated by facility staff without the required physician documentation or orders. The DON completed the necessary forms at the direction of corporate staff, but the forms were not signed by a physician and lacked detailed medical justification. Hospital evaluation found no immediate safety concerns, and the resident's medical record did not contain physician progress notes or orders supporting the transfer or discharge.
A resident with complex psychiatric and medical needs was transferred to a hospital for evaluation after exhibiting aggressive behavior. Despite being cleared for return, the facility did not allow the resident to come back, failed to document the basis for discharge, and did not provide the required discharge notice or summary, in violation of facility policy and regulatory requirements.
The facility failed to communicate necessary information to receiving health care providers for two residents transferred to the hospital. One resident with intellectual disabilities and dementia showed symptoms requiring hospital transfer, but the facility did not document communication of care plan goals or advanced directives. Another resident with high blood pressure and depression was also transferred without documented communication of essential information. The Nursing Home Administrator confirmed these deficiencies.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
Discharge Executed While Appeal Pending and Without Adequate Planning
Penalty
Summary
A resident was discharged from the facility while an appeal of her discharge was still pending. The resident had received a 30-day discharge notice due to nonpayment and was informed of her right to appeal. Documentation shows that the resident filed her appeal on what the facility determined was the 11th day after notice, rather than within the 10-day window, and the facility proceeded with the discharge prior to the scheduled hearing date. Both the facility and the resident had received notice of the upcoming hearing, but the discharge was carried out before the appeal was heard. The resident had multiple complex medical conditions, including chronic hepatic failure, COPD, chronic respiratory failure, heart failure, lymphedema, morbid obesity, dysphagia, depression, and anxiety. At the time of discharge, she required significant assistance with transfers, was dependent on a sit-to-stand lift, and used a wheelchair as her primary mode of mobility. Therapy and social services notes indicated that not all necessary equipment, such as the sit-to-stand lift and upright walker, were available at her home at the time of discharge. The resident also reported not having a finalized schedule for home health services and expressed distress about being dependent on a male family member for personal care, which she found undignified and uncomfortable. Facility records and interviews confirm that the discharge was executed despite the pending appeal and without all recommended equipment and services in place. The facility's policy requires a safe, orderly, and planned discharge, including ensuring the resident's needs are met at the discharge location. The resident's care plan and therapy recommendations highlighted the need for specific equipment and support, which were not fully arranged at the time of discharge.
Failure to Send Comprehensive Care Plan Goals During Resident Transfer
Penalty
Summary
The facility failed to include the resident's comprehensive care plan goals in the required documentation during a transfer to the hospital. Record review showed that one resident was hospitalized, and interviews with both a Registered Nurse/Unit Supervisor and a Licensed Practical Nurse confirmed that the care plan goals were not sent with the resident upon transfer. The surveyor discussed this concern with the Director of Nursing.
Failure to Obtain Required Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the required physician documentation was included in the medical record to support a resident's transfer and discharge rights. A resident with a history of schizophrenia and elopement behaviors was admitted to the facility and, shortly after admission, attempted to leave the facility twice. Following these incidents, facility staff initiated a Petition for Involuntary/Judicial Admission and a Notice of Involuntary Transfer or Discharge (IVD), citing the safety of individuals in the facility as the reason for the proposed transfer or discharge. However, the forms were completed by the Director of Nursing at the instruction of corporate personnel, and not by a physician. The IVD form indicated that the transfer was not an emergency, and the petition lacked detailed physician input or signature. Review of the resident's medical record and hospital documentation revealed that there were no physician orders for the involuntary psychiatric admission or for discharge. The hospital evaluation found no acute psychiatric or medical condition requiring intervention, and the petition from the facility was deemed invalid due to the lack of clear immediate safety concerns and improper completion. Additionally, the resident's electronic medical record contained no progress notes from a nurse practitioner or physician regarding the need for involuntary discharge or psychiatric admission, and behavioral monitoring documentation by CNAs was incomplete, only noting the resident as "not available." Facility policy requires physician confirmation and documentation in the medical record to support emergency transfers or discharges, as well as clear documentation of the danger posed by the resident. In this case, the required physician documentation and orders were absent, and the forms were not properly completed or signed by a physician, resulting in a failure to meet regulatory requirements for transfer and discharge rights.
Failure to Document and Notify Resident Discharge After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident with diagnoses including dementia, paranoid schizophrenia, major depressive disorder, legal blindness, and anxiety was transferred to a hospital for a psychological evaluation following aggressive and combative behavior, including breaking a window and being combative with staff. Despite being cleared medically and psychiatrically at the hospital, the resident was not allowed to return to the facility. The facility did not document the basis for the resident's discharge, nor did it provide the required discharge summary or notice to the resident or their representative. The care plan for the resident was marked as cancelled and resolved shortly after the transfer, and there was no evidence in the records of a formal discharge process or communication of the discharge decision. Interviews with facility administration and the resident's family confirmed that the resident was not permitted to return due to behavioral concerns, despite the facility's awareness of these behaviors at the time of admission. Facility policy states that residents must be permitted to return following hospitalization unless specific criteria are met and that not permitting a resident to return constitutes a discharge. The lack of documentation and failure to follow the required discharge process could result in residents not having the opportunity to appeal the discharge, as noted in the findings.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. Resident R47, who had diagnoses of intellectual disabilities, dementia, and major depressive disorder, was transferred to the hospital after exhibiting symptoms such as elevated blood pressure, right-sided facial droop, and left arm weakness. Despite the transfer, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, or specific instructions for ongoing care to the hospital. Similarly, Resident R76, who had diagnoses of high blood pressure, depression, and dementia, was transferred to the hospital due to elevated blood pressure and a headache. The facility also failed to document the communication of necessary information to the receiving health care provider, including the resident's care plan goals, advanced directive information, and resident representative information. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution for these two residents. This deficiency was identified based on a review of facility policies, resident records, and staff interviews.
Plan Of Correction
1. The facility is unable to go back and make certain that specific information was communicated to the receiving health care provider during resident transfers. 2. DON/designee to educate licensed staff on comprehensive transfer protocol regarding providing specific information to receiving health care provider and appropriate documentation on the event. 3. DON/designee to audit hospital transfers to ensure proper documentation is sent 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 4. Results to be submitted to QAPI for review and approval.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
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