Failure to Ensure Safe Transfer of Resident to Hospital
Summary
The facility failed to ensure a safe and orderly transfer of a resident to a General Acute Care Hospital (GACH) following a change in condition. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was transferred without proper identification and with incorrect medical records. The resident's medical history and medication information were not accurately communicated to the receiving facility, which could have led to delays in treatment or incorrect medical interventions. The incident occurred when the resident experienced a change in condition, including hypotension and tachycardia, and was transferred via emergency services. However, the medical records sent with the resident belonged to a different resident, who was the roommate of the transferred resident. This error was discovered after the resident arrived at the GACH, leading to confusion and a delay in obtaining the correct medical records. The facility's Director of Nursing (DON) confirmed that the RN supervisor was responsible for ensuring the correct documentation was sent, but the RN on duty was from a Nursing Registry and unfamiliar with the facility's procedures. Interviews with facility staff and the GACH ER Case Manager revealed that the facility identified residents by room and bed numbers, which contributed to the mix-up. The resident was not wearing an identification wristband, which was against the facility's policy. The DON acknowledged the error and the potential for delayed treatment due to the incorrect records being sent. The facility's policy on transfers and discharges was not followed, leading to this deficiency.
Penalty
A resident with multiple complex medical conditions was subject to an emergency discharge after being accused by two other residents of possessing a firearm, though no weapon was found. The resident was denied re-entry, police were called, and the resident was discharged without a safe destination or arrangements for ongoing wound care. The resident's belongings were placed by the dumpster, and the individual left the property in a wheelchair without transportation or a coat, later spending two days in a car before being hospitalized.
Facility staff did not provide or document sufficient preparation and orientation for a resident with multiple complex diagnoses and moderate cognitive impairment before transfer to a higher level of care. The clinical record lacked required details about the transfer process, and the DON confirmed that discharge documentation was incomplete, contrary to facility policy.
A resident with multiple medical conditions was discharged home with the expectation of receiving home health services, but the facility did not confirm that these services were in place before discharge. The resident did not receive the needed care, contacted the facility for assistance, and reported a fall after discharge. Facility staff did not follow up with the home health agency or the resident to ensure continuity of care, and authorization from the VA was still pending.
A resident was transferred to the hospital without the required documentation, care plan goals, or belongings, and neither the resident nor their responsible party received necessary information prior to transfer. The transfer decision was made by the DON due to behavioral concerns, without assessment by a facility physician or psychiatric services, and hospital staff confirmed that no paperwork or bed hold notice was provided.
A resident with multiple medical conditions and significant care needs was discharged without home health services being properly arranged. Although staff believed arrangements had been made, the selected home health agency did not serve the resident, and no follow-up calls were documented to verify post-discharge care. This resulted in the resident not receiving necessary home health support after leaving the facility.
A resident with multiple medical and mental health conditions was discharged without sufficient preparation or documentation, including missing discharge MDS, lack of a physician's discharge order, and no follow-up after the resident chose to be transported to a motel instead of a shelter. The facility did not ensure proper discharge planning or post-discharge contact, as required by policy.
Failure to Provide Safe and Orderly Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was subject to an emergency discharge following allegations from two other residents that the individual possessed a firearm and had made threats. The resident, who had diagnoses including unspecified paraplegia, a stage III pressure ulcer, chronic pain syndrome, malnutrition, morbid obesity, bipolar disorder, and neuromuscular bladder dysfunction, left the facility without signing out and was later refused re-entry. Despite multiple attempts by the social worker to secure alternative placement and community resources, no emergency housing or LTC facility would accept the resident, and the resident was unavailable to participate in discharge planning. When the resident returned to the facility, staff, following instructions from administration and police, did not allow entry and called law enforcement. Police searched the resident and found no weapon. The resident was given discharge paperwork, a face sheet, a medication list, and routine medications (excluding narcotics), but was not provided with a safe discharge destination or arrangements for ongoing wound care. The resident's belongings were packed in trash bags and placed by the dumpster, and the resident left the property in a wheelchair without a coat or transportation, ultimately spending two days in a car before being hospitalized for a stomach infection. Interviews with staff, the Ombudsman, and police confirmed that the resident was discharged without a safe destination, and that the facility's discharge notice inaccurately listed a destination. The resident did not take any belongings with him, and staff were unclear about his whereabouts after leaving. The facility's own policy required advance preparation for discharge, including assistance with transportation and ensuring a safe discharge location, but these steps were not followed in this case.
Failure to Document and Prepare Resident for Safe Transfer/Discharge
Penalty
Summary
Facility staff failed to provide and document adequate preparation and orientation for a resident prior to transfer or discharge to a higher level of care. The clinical record lacked sufficient documentation to demonstrate that the resident was properly prepared or oriented for the transfer, as required by facility policy. The only progress note available for the transfer was brief and did not include necessary details about the preparation or orientation provided to the resident. The resident involved had multiple significant diagnoses, including heart failure, chronic respiratory failure, atrial fibrillation, and anxiety disorder, and was assessed as moderately cognitively impaired. The DON confirmed that the family requested the transfer due to increased confusion, but acknowledged that the nurse responsible did not accurately document the discharge process. Facility policy requires thorough documentation of all services, changes in condition, and communication with family or other staff, which was not met in this instance.
Failure to Ensure Home Health Services in Place Prior to Discharge
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident who was discharged home with the expectation of receiving home health services. The resident, who had a history of a right acetabulum and pubis fracture, Type 2 Diabetes Mellitus, and long-term insulin use, was discharged with arrangements for physical therapy, occupational therapy, and nursing services through a home health agency (HHA). Although the facility's social services staff faxed referral documents to the HHA, there was no evidence that the facility confirmed receipt of the referral or that services were in place prior to discharge. After discharge, the resident contacted the facility to report that he had not received the expected caregiver services and had already experienced a fall at home. Interviews with facility staff revealed that the social services department did not typically follow up with HHAs or discharged residents unless notified by the HHA of an issue. The HHA reported they had not seen the resident because they were awaiting VA authorization and had been unable to contact the resident. Documentation showed that the VA had not processed the authorization request in a timely manner, and the HHA had not received the necessary information to proceed. The facility's policy required social services to ensure continuity of care during discharge, but in this case, the lack of confirmation and follow-up resulted in the resident not receiving needed home health services.
Failure to Provide Required Documentation and Information During Resident Transfer
Penalty
Summary
The facility failed to provide required documentation and information to a resident or their responsible party prior to transferring the resident to the hospital. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other necessary information were sent to the hospital at the time of transfer. Additionally, there was no evidence that the resident or their responsible party received education or review of the specific information required to be sent to the receiving facility. The resident's belongings were also not sent with them, and no bed hold notice was provided. Interviews with facility staff, including the DON, hospital liaison, and medical director, revealed that the decision to transfer the resident was made by the DON due to behavioral concerns, but the resident had not been assessed by a facility physician or psychiatric services prior to transfer. Communication between facility staff and the hospital was limited to verbal notification, and the hospital social workers confirmed that no paperwork or belongings accompanied the resident. The medical director stated they had no input in the transfer decision.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were arranged prior to the discharge of a resident with significant medical needs. The resident, who had diagnoses including cerebral infarction, hemiplegia, hemiparesis, vascular dementia, dysphagia, impulse disorder, major depression, and intermittent explosive disorder, required assistance with most activities of daily living and was incontinent. Although the social worker faxed information to a home health agency before discharge, the agency later confirmed they did not have the resident as a client and did not serve individuals under the age of 60. The resident reported not receiving any home health services after discharge. Interviews with facility staff, including the Social Service Designee, Administrator, and DON, revealed they believed home health services had been arranged, but were unaware that the resident was not receiving them. Review of facility policy indicated that discharge planning should include arranging for home health and follow-up calls post-discharge, but there was no documented evidence that follow-up calls were made to the resident after discharge. This deficiency was identified during a complaint investigation and affected one resident out of three records reviewed.
Failure to Provide and Document Safe Discharge Preparation
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge of a male resident with multiple diagnoses, including cerebral ischemia, generalized anxiety disorder, hypertensive urgency, lack of coordination, and cognitive communication deficit. The resident was admitted to the facility and later discharged, but the records showed that key sections of the Minimum Data Set (MDS) assessment related to discharge were left blank, and a discharge MDS was not completed. The care plan indicated the resident's wish to return home and outlined steps for discharge planning, but there was no evidence of a physician's discharge order or comprehensive discharge planning documentation. The resident received a 30-day discharge notice due to failure to pay, and while the facility staff made referrals to other facilities, the resident refused these placements. On the day of discharge, the resident requested to be taken to a motel instead of a homeless shelter, and the facility van driver transported him to the motel, assisted with his belongings, and notified the administrator of the location. However, there was no follow-up by the facility to check on the resident's wellbeing or safety after discharge, and the resident's contact information was not documented for follow-up. Progress notes and interviews confirmed that the facility did not attempt to contact the resident post-discharge. Facility policy required discharge planning to ensure safe and appropriate transitions, including physician orders and communication with continuing care providers. Despite this, the facility did not complete the required discharge documentation, did not ensure a physician's order for discharge, and did not follow up with the resident after he left the facility. These actions and omissions resulted in a lack of documented preparation and orientation for the resident's discharge, as required by policy and regulation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.