Failure to Document Transfer and Discharge Reasons
Summary
The facility failed to document adequately the reasons for not meeting the needs and readmitting a resident who was transferred and discharged. The resident, who had multiple diagnoses including multiple sclerosis, bipolar disorder, and anxiety, was initially admitted in June 2023. Despite being stable and cooperative according to a psychiatric note, the resident exhibited disruptive behavior, leading to an emergency discharge to the hospital. The facility did not document the course of events or the rationale for not allowing the resident to return. The resident was involved in incidents that included attempting to exit the building and expressing suicidal ideation, which led to involuntary examinations and hospitalizations. The facility's documentation did not reflect these events accurately, and the resident's medical record lacked clear documentation of the transfer and discharge process. The facility's policy required documentation of efforts to ascertain the resident's condition and needs, which was not fulfilled. Interviews with facility staff revealed that the resident was considered a long-term care resident with no discharge plans. The Nursing Home Administrator and Director of Nursing acknowledged the lack of documentation and the failure to assess the resident in person. The facility's refusal to readmit the resident after hospitalization was not properly documented, and the resident's family was not informed of the discharge decision until contacted by the hospital.
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.
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 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.
A resident with multiple complex diagnoses was admitted without medications, personal items, or adequate behavioral information from the previous facility. After exhibiting sexually inappropriate behavior, the facility determined it could not meet the resident's needs and attempted to return the resident the same day without proper coordination or documentation. The original facility refused readmission, resulting in the resident being sent to the hospital due to lack of placement.
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 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 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 Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was admitted with multiple diagnoses, including Autistic Disorder, Epilepsy, Dysphasia, and Cognitive Communication Deficit Disorder. Upon admission, the resident arrived without medications, a medication list, personal items, and was soiled. The facility did not receive adequate communication from the discharging facility regarding the resident's behavioral issues, specifically sexually inappropriate behaviors, which were not documented on the face sheet or communicated prior to transfer. After admission, the resident exhibited sexually inappropriate behavior toward female staff, which the facility was unprepared to manage. The Director of Nursing and Administrator determined they could not meet the resident's needs and decided to return the resident to the original facility. The process was not coordinated, and the original facility refused to readmit the resident, leading to involvement from the police and Adult Protective Services. The resident ultimately was sent to the hospital due to lack of placement. The facility's actions did not follow their own Transfer and Discharge policy, which requires written notice, documentation of the reason for transfer or discharge, and communication with the resident, their representative, and the Long-Term Care Ombudsman. The discharge was rushed, lacked proper documentation, and failed to ensure the resident's safety and continuity of care, resulting in the resident being left without appropriate placement.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
