Inadequate Management of Involuntary Discharge for Resident with Severe Mental Health Issues
Summary
The facility failed to appropriately manage the involuntary discharge of a resident, identified as R1, who had a history of severe mental health issues, including Bipolar disorder, Generalized Anxiety, and Conversion Disorder with Seizures. R1 required continuous supervision and had a documented history of aggressive behaviors, including verbal and physical aggression towards staff and peers, as well as attempts to elope from the facility. Despite these challenges, the facility did not ensure that a signed physician discharge order was in place when serving a notice of involuntary discharge. The report details several incidents involving R1 that led to her being sent to a local hospital for psychiatric evaluation. These incidents included physical altercations with other residents, attempts to leave the facility, and aggressive behavior towards staff. On one occasion, R1 was involved in a physical altercation with another resident, and on another, she attempted to break windows and spat on staff. Despite these behaviors, the facility's documentation did not include a signed physician order for R1's discharge, which is a requirement for involuntary discharge. Interviews with facility staff, including the Director of Nursing and a Certified Nursing Assistant, revealed that R1's aggressive behaviors were consistent and not new. However, on the day of the involuntary discharge, R1's behavior was described as being at a new level of severity. The facility's failure to obtain a signed physician order for the discharge, despite the documented need for such an order, constitutes a deficiency in the facility's handling of the situation.
Penalty
A facility failed to document the hospital transfer of a resident with multiple health issues, including heart failure and diabetes. The resident was sent to the hospital due to low oxygen saturation, but the medical record lacked documentation of this transfer. The DON confirmed the absence of necessary records.
The facility failed to provide proper documentation and justification for the discharge of two residents. One resident was discharged without a documented notice, and the discharge summary lacked essential information. Another resident was discharged AMA before the end of a 30-day notice period due to behavioral issues, but the discharge process did not comply with regulatory requirements. Interviews with staff revealed a policy prohibiting unsupervised departures due to safety concerns, but the facility did not follow proper procedures for the discharges.
A facility failed to provide comprehensive transfer information for a resident who had Alzheimer's, diabetes, and other conditions. The Transfer Form omitted the resident's son as the power-of-attorney, which was confirmed by the Administrator.
A resident with severe cognitive impairment was discharged from the facility without a physician's order or proper documentation. The responsible party was informed via phone and text, but a written notice was sent after the discharge. The facility's policy required documentation and a physician's order, which were not provided.
A facility failed to document and notify a physician before a resident's hospital transfer. The resident, with conditions including diabetes and chronic kidney disease, requested emergency room care due to a bloated stomach. The Vice President of Operations confirmed missing transfer papers and lack of physician notification, contrary to the facility's policy requiring detailed observations before such actions.
A facility failed to issue a 30-day discharge notice for a resident transitioning from Medicare Part A to private pay. The resident, with multiple medical conditions and cognitive impairment, required significant assistance. The resident's family was informed of the need for Medicaid application, but due to the lack of a power of attorney, the process was delayed. The facility had no long-term care beds available, and the family chose to take the resident home. The facility's policy allows for transfers even with a pending Medicaid application, but the absence of a discharge notice led to the deficiency.
Failure to Document Resident's Hospital Transfer
Penalty
Summary
The facility failed to ensure proper documentation for the discharge of a resident, identified as Resident #85, who was hospitalized. The resident, who had been admitted with diagnoses including metabolic encephalopathy, heart failure, severe protein-calorie malnutrition, type two diabetes mellitus, and chronic kidney disease, was transferred to the hospital due to low oxygen saturation as ordered by a doctor. However, there was no documentation in the medical record regarding the transfer to the hospital. This lack of documentation was confirmed through interviews with the Director of Nursing, who acknowledged the absence of records related to the resident's transfer.
Improper Discharge Procedures for Two Residents
Penalty
Summary
The facility failed to provide proper documentation and justification for the discharge of Resident #400, who was admitted with diagnoses including major depressive disorder and schizoaffective disorder. The resident was discharged without a documented discharge notice, and the discharge summary lacked essential information such as the reason for discharge and treatment provided. The facility's Administrator stated that the resident was discharged for smoking marijuana, but there was no documentation to support this claim. The Director of Nursing confirmed the absence of a discharge notice in the resident's medical record. Resident #100 was also affected by the facility's failure to adhere to proper discharge procedures. Despite being on a 30-day discharge notice due to behavioral issues, the resident was discharged against medical advice (AMA) before the notice period ended. The resident's discharge summary was incomplete, missing details about follow-up care and community resources. The facility's staff reported that the resident violated a behavior agreement by leaving the facility without supervision, which led to the AMA discharge. However, the discharge process did not comply with regulatory requirements, as the resident was not allowed to remain in the facility for the duration of the discharge notice. Interviews with facility staff, including the Administrator and the Director of Nursing, revealed that the facility had a policy prohibiting residents from leaving without supervision due to safety concerns in the area. Both residents had signed behavior agreements that outlined conditions for their continued residency, but the facility did not provide adequate documentation or follow proper procedures for their discharges. The lack of proper discharge notices and incomplete discharge summaries indicate a deficiency in the facility's compliance with regulatory standards for resident transfers and discharges.
Failure to Provide Accurate Transfer Information
Penalty
Summary
The facility failed to ensure comprehensive resident information was provided to the receiving facility during a transfer, affecting one resident reviewed for death. The resident, who had diagnoses including Alzheimer's disease, diabetes mellitus, anxiety disorder, depression, and a personal history of malignant neoplasm, was admitted to the facility and later expired there. A review of the resident's Transfer Form revealed that the facility did not include accurate information regarding the resident's representative, specifically omitting the resident's son, who was the power-of-attorney (POA)/resident representative. This omission was confirmed during an interview with the Administrator.
Resident Discharged Without Proper Documentation or Physician's Order
Penalty
Summary
The facility discharged a resident without a physician's order or proper documentation of a rationale for the discharge. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was transferred to another facility without a documented discharge notice or reason in the medical record. The facility's policy required documentation of the reasons for discharge and a physician's order, neither of which were present in this case. The resident's responsible party was informed of the discharge via a phone call and text message, but did not receive a written notice until after the discharge had occurred. The facility sent a 30-day discharge notice via certified mail after the resident had already been transferred. The Medical Director confirmed that she was notified of the discharge but did not document the basis for it or write a discharge order. The facility's policy required such documentation, highlighting a failure to adhere to established procedures.
Failure to Document and Notify Physician Before Hospital Transfer
Penalty
Summary
The facility failed to ensure proper documentation and physician notification before the hospitalization of a resident. The resident, who was cognitively intact and required setup assistance for activities of daily living, was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and malignant neoplasm of the duodenum. On the day of the incident, the resident requested to go to the emergency room due to a bloated stomach, and emergency services were called. However, there was no documentation in the medical record indicating that the resident was assessed prior to the hospital transfer. An interview with the Vice President of Operations confirmed that the hospital transfer papers were missing from the medical chart, and there was no evidence that the doctor was notified about the transfer. The facility's policy on changes in a resident's condition or status, revised in December 2016, requires nurses to make detailed observations and gather relevant information before notifying the physician or healthcare provider. This policy was not followed in the case of the resident's transfer to the hospital.
Failure to Issue 30-Day Discharge Notice for Resident Transitioning to Private Pay
Penalty
Summary
The facility failed to ensure a resident was permitted to stay once their payer source changed from Medicare Part A to private pay. The resident, who had medical diagnoses including nontraumatic subarachnoid hemorrhage, cirrhosis, hepatic encephalopathy, anorexia, and congestive heart failure, was admitted with moderately impaired cognition and required significant assistance with daily activities. Upon exhausting Medicare services, the resident's daughter was informed that the resident would become private pay and requested the facility to begin the Medicaid process. However, the facility did not issue a 30-day discharge notice, and the resident's family ultimately took the resident home with home health services. The Social Service Director stated that the Medicaid process could not start without a power of attorney or guardianship due to the resident's cognitive impairment. The facility's administrator confirmed that there were no long-term care beds available and offered to assist with transferring the resident to another facility. Despite this, the family chose to take the resident home. The facility's policy allows for transfers and discharges even if a Medicaid application is pending, but the lack of a 30-day discharge notice and the communication regarding bed availability contributed to the deficiency.
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.
