Failure to Address Resident's Discharge Goals and Needs
Summary
The facility failed to address the discharge goals and needs of a resident with moderate cognitive impairment, as indicated by a BIMS score of 12/15. The resident, diagnosed with alcohol cirrhosis of the liver with ascites, non-Alzheimer's dementia, and Diabetes Mellitus, expressed a desire to leave the facility and return home. Despite the resident's verbalized wishes and inquiries about discharge, the facility did not initiate any discharge planning or evaluate the resident's mental capacity to make such decisions. The resident's care plan required quarterly reviews of discharge plans, but there was no documentation of Durable Power of Attorney or mental capacity documents to indicate the resident's inability to make medical decisions. The facility's social worker only advised the resident to discuss discharge with family members, who were reportedly non-responsive and opposed to the resident returning home. The facility's administrator acknowledged the lack of a designated decision-maker for the resident and was uncertain if guardianship had been pursued. The facility's policy on Transfer/Discharge Criteria lacked guidance on discharge planning according to resident goals or determining medical decision-making capacity, contributing to the deficiency in addressing the resident's discharge needs.
Penalty
A resident with moderate cognitive impairment and multiple medical conditions expressed a desire to move to assisted living, but the care plan continued to reflect a long-term stay in the facility. Although the social worker was aware of the resident's goal and began working on placement, the care plan was not updated to match the resident's current wishes, as confirmed by both the SW and DON.
A resident with intact cognition and good discharge potential was not regularly re-evaluated, referred, or provided documented referrals to local agencies for discharge planning. Despite being eligible and expressing a desire to move to assisted living, the resident received no updates or assistance after an initial referral discussion, and staff confirmed there was no record of a formal referral or updated care plan, due in part to recent staff turnover in social services.
A resident with multiple fractures and significant care needs was discharged without a comprehensive care plan, proper coordination with outside providers, or complete discharge instructions. The facility did not ensure necessary medical equipment was ordered or that referrals and follow-up care were arranged, resulting in an incomplete and inadequate discharge process.
A resident with diabetes was discharged without receiving necessary education on insulin administration, diabetes management, or use of a glucometer, and was also sent home without prescribed medications and supplies due to a lack of medication reconciliation and communication among staff.
A resident with multiple fractures and a traumatic pneumothorax was discharged without the home health services specified in their care plan and physician orders. Although referrals to home health agencies were made, none accepted the resident, and there was no documentation confirming that services were scheduled. The resident's spouse reported not being contacted by any agency, and staff confirmed the discharge plan was not implemented as required.
A resident with a history of a leg fracture and diabetes was discharged after improvement, but required post-discharge follow-up calls were not documented in the medical record. Interviews with the SSD and DON confirmed that facility policy mandates follow-up calls within 72 hours and again between 14-28 days post-discharge, but there was no evidence these were completed or recorded for the resident.
Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.
Failure to Re-Evaluate and Document Discharge Planning for Resident
Penalty
Summary
The facility failed to regularly re-evaluate, refer, and document referrals to local contact agencies for discharge planning and assessment for one resident. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and osteoarthritis, was found to have intact cognition and required only supervision or minimal assistance with activities of daily living. Despite being assessed as having good discharge potential and expressing a desire to be discharged to an assisted living facility, the resident reported not receiving updates or assistance regarding discharge planning after an initial referral discussion with a previous social worker. The resident stated he had not been informed of any progress or timeline for discharge and was concerned about having nowhere to go if the facility did not assist him. Staff interviews revealed that the social services department had experienced significant turnover, with most social workers having left and a new team recently starting. The Social Services Director confirmed that there was no record of a referral for discharge assessment in the facility's referral tool, despite the resident's eligibility and readiness for community discharge. The resident's care plan and assessments had not been updated as required, and there was a lack of ongoing communication and documentation regarding discharge planning, contrary to facility policy and standard practice.
Failure to Implement Effective Discharge Planning and Coordination
Penalty
Summary
The facility failed to implement an effective discharge process for Resident #394, as evidenced by several deficiencies in planning and coordination. The resident, who was admitted following multiple fractures and required maximal to moderate assistance with activities of daily living, was discharged home after insurance coverage ended. Despite the resident's complex needs, including non-weight-bearing status, limited mobility, incontinence, and the need for intermittent self-catheterization, the facility did not develop a comprehensive discharge care plan, coordinate referrals to outside providers, or order the recommended medical equipment. Additionally, the discharge packet was incomplete, lacking a home medication list and other essential information at the time of discharge. The record review and staff interview confirmed that only an initial care conference was held, with no further documented planning or coordination for the resident's transition to home. The discharge paperwork was initiated late and was incomplete, and there was no evidence of proper coordination with home health agencies or vendors for necessary services and equipment. The physician's discharge summary outlined ongoing care needs and follow-up appointments, but the facility did not ensure these were addressed in the discharge process.
Failure to Provide Discharge Education and Medication Reconciliation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, among other diagnoses, was discharged from the facility without receiving necessary education on diabetes management, specifically regarding the use of newly prescribed Insulin Lispro, insulin sliding scale, and self-injection techniques. The clinical record and facility documentation showed that the resident did not receive teaching or training on diabetes care, use of a glucometer, or insulin administration during their stay, despite care plans and physician orders indicating these needs. Nursing notes failed to document any education provided on these critical aspects of diabetes self-management prior to discharge. Additionally, the facility failed to perform proper medication reconciliation before the resident's discharge. The discharge summary and medication list indicated that the resident was to continue with Insulin Lispro and gabapentin, but these medications and necessary supplies were not provided to the resident upon discharge. Communication breakdowns between nursing staff and the prescribing provider led to the assumption that the resident had all required medications, resulting in the omission of new prescriptions and supplies needed for safe transition home. Interviews with facility staff confirmed that the resident was discharged without the prescribed medications and without the required education on their use. The facility's own discharge planning policy required reconciliation of all pre- and post-discharge medications and provision of education, but these steps were not completed. The deficiency was identified after the home care nurse reported the missing medications and lack of discharge teaching, prompting an internal investigation that confirmed the failures in discharge planning and education.
Failure to Provide Discharge Planning Focused on Resident's Needs
Penalty
Summary
The facility failed to provide adequate discharge planning for one resident, as required by regulation. The resident was admitted with multiple serious injuries, including fractures to the ribs, right tibia, cervical spine, and a traumatic pneumothorax. The clinical record indicated that the resident was to be discharged with home health services, including PT, OT, RN, and aide support, as per physician orders and social services assessments. However, the discharge plan documentation showed that the resident was discharged without these home health services. Facility records revealed that referrals were made to home health agencies, but these agencies were unable to accept the resident for services. There was no documentation in the progress notes confirming that home health services were scheduled or provided. Additionally, the resident's spouse contacted the facility to report that they had not been contacted by any home health agency. During staff interviews, it was confirmed that the facility did not implement the required discharge plan for the resident.
Failure to Document Post-Discharge Follow-Up
Penalty
Summary
The facility failed to ensure that a post-discharge follow-up was conducted and documented in the medical record for one resident. The resident, who had a history of a left tibia fracture and type 2 diabetes mellitus, was admitted to the facility and later discharged after his health improved. Documentation review showed that there was no evidence of a follow-up call or contact with the resident after discharge, as required by facility policy. The Social Service Director confirmed that follow-up calls should be made within 72 hours post-discharge and that records of such calls are maintained, but was unable to confirm whether the case manager completed this for the resident in question. Further interviews with the Director of Nursing revealed that both social services and case management are responsible for conducting and documenting follow-up calls at specific intervals after discharge. Review of facility policies confirmed the requirement for timely follow-up calls and accurate documentation in the medical record. However, there was no documentation indicating that the required post-discharge follow-up was completed for the resident, resulting in a deficiency related to discharge planning and documentation.
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.
