Failure in Comprehensive Discharge Planning for a Resident
Summary
The facility failed to provide ongoing, comprehensive discharge planning for a resident, identified as R49, who was reviewed for discharge planning. R49 was admitted to the nursing home from an acute hospital and initially had an active discharge plan to return to the community. However, subsequent assessments indicated that no active discharge plan was in place, and no referrals to local agencies were made, as they were reportedly not wanted. Despite R49's expressed desire to move to an Assisted Living Facility (ALF) and the completion of a necessary assessment for ALF qualification, the facility did not follow through with the discharge planning process. R49's progress notes revealed that the resident expressed interest in moving to an ALF or a group home, but the facility's social services department did not follow up on these requests. Although a care conference was held, and contact information for assisted living locators was provided, there was no documentation of follow-up actions to assist with ALF referrals or discharge planning. Interviews with the resident and facility staff confirmed that the resident's discharge wishes were not adequately addressed, and the social services department did not complete the necessary referrals or follow-up actions. The facility's discharge planning policy indicated that discharge planning should start at admission, with efforts made to meet the resident's goals. However, the social services designee and regional licensed social worker acknowledged that the necessary follow-up actions were not taken, and the resident's discharge planning process was not completed. The administrator confirmed that the social services department was responsible for assisting residents with discharge planning, but the process was not effectively carried out for R49.
Penalty
The facility failed to obtain discharge physician orders for three residents, contrary to its policy. One resident with cirrhosis and diabetes was discharged without a physician order, despite receiving a discharge summary and medication list. Another resident with malignant neoplasm and diabetes was discharged home after medication review, but without a physician order. A third resident with portal vein thrombosis and depression was discharged after reviewing paperwork with her mother, also without a physician order. Staff interviews confirmed the absence of required discharge orders.
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. One resident was discharged to an assisted living facility without proper documentation or updates to the care plan, while another resident's desire to move to South Carolina was not reflected in the discharge plan. The facility did not adequately document or update the discharge plans, violating its own policy.
The facility failed to ensure proper discharge planning for two residents, resulting in unmet needs. One resident did not receive ordered home health services due to insurance issues and communication failures, while another had incomplete discharge documentation. The facility's policy for comprehensive discharge planning was not followed, leading to deficiencies in coordinating post-discharge services.
A facility failed to honor a resident's choice of home health agency upon discharge. The resident, who required supervision for daily activities and had multiple health diagnoses, was discharged without receiving their preferred home health service. The Social Services Designee did not follow up with the resident for an alternative choice after the preferred agency did not return calls, instead selecting a service themselves, contrary to the facility's policy.
A resident with a history of bipolar disorder and opioid dependence was discharged AMA to live with her son, despite a psychological evaluation indicating moderate cognitive impairment and the need for a guardian. The facility failed to address the primary POA's concerns about the discharge's safety and did not notify her until after the resident had left. The facility did not contact adult protective services or the police, leading to a deficiency in ensuring a safe discharge process.
A resident with multiple health conditions requested a transfer closer to Ohio, but the facility failed to provide timely assistance with referrals. Initial referrals were made, but there was no follow-up or ongoing discharge planning for several months. The Social Services Director confirmed the lack of assistance and failure to provide a list of in-network facilities, contrary to the facility's discharge planning policy.
Failure to Obtain Discharge Physician Orders
Penalty
Summary
The facility failed to obtain a discharge physician order for residents being discharged, affecting three out of four residents reviewed for discharge. Resident #69, who had diagnoses including cirrhosis of the liver and type two diabetes mellitus, was discharged without a physician order. The resident's progress notes indicated that the family took her home, and she was provided with a discharge summary and medication list, but no discharge order was documented in the medical record. Similarly, Resident #174, with diagnoses such as malignant neoplasm and type two diabetes mellitus, was discharged home without a physician order. The progress notes showed that the resident was alert and oriented, and the nurse reviewed medications with the resident and their power of attorney. Resident #175, diagnosed with conditions including portal vein thrombosis and major depressive disorder, was also discharged without a physician order. The progress notes indicated that the resident was discharged after reviewing the medication list and discharge paperwork with her mother. Interviews with facility staff confirmed the absence of discharge orders for these residents, which was contrary to the facility's discharge planning policy requiring a physician order for discharges.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. Resident #125, who had intact cognition and required supervision for activities of daily living, was discharged to an assisted living facility without documented changes to the discharge plan or updates to the care plan. The social worker confirmed that no updates were made to the medical record regarding the discharge planning process, indicating a lack of proper documentation and planning. Resident #126, who also had intact cognition but required moderate to maximum assistance for activities of daily living, expressed a desire to move to South Carolina to be closer to family. Despite this, the discharge care plan was not updated to reflect this change, and there was no documentation of the discharge planning process in the medical record. The resident was discharged with arrangements made for a flight and transportation, but the discharge summary lacked details about the hospital or potential facilities for placement in South Carolina. Interviews with facility staff and external parties involved in the discharge process revealed that the facility did not adequately document or update the discharge plans for these residents. The facility's policy required regular re-evaluation and updates to the discharge plan, which were not followed in these cases. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with discharge planning requirements.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge planning for two residents, leading to unmet discharge needs. Resident #22 was discharged home with orders for physical therapy, occupational therapy, and skilled services, but there was no evidence of discharge goals in the care plan. After discharge, the resident did not receive the ordered home health services, including therapy and nursing, due to insurance issues and communication failures. The resident also experienced delays in receiving a wheelchair and reported falls at home. Interviews revealed that the Social Services Designee (SSD) was not aware of the insurance denial until after discharge and had difficulties coordinating the necessary services. Resident #33 was discharged home with orders for therapy and nursing services, but the care plan lacked discharge planning documentation. The discharge summary and instructions were incomplete, with no nursing review or medication list provided. The Director of Nursing confirmed the absence of discharge notes and care plans for this resident. The facility's policy required comprehensive discharge planning, but this was not followed, resulting in inadequate preparation for the resident's transition home. The facility's failure to adhere to its discharge policy and ensure coordination of post-discharge services led to deficiencies in discharge planning for both residents. The lack of timely communication and follow-up with home health providers and durable medical equipment suppliers contributed to the residents' unmet needs and challenges after leaving the facility.
Failure to Honor Resident's Choice of Home Health Agency
Penalty
Summary
The facility failed to ensure that a resident received the home health company of their choice upon discharge. The resident, who was cognitively intact and required supervision with various activities of daily living, was discharged with diagnoses including acute on chronic diastolic heart failure, chronic obstructive pulmonary disease, and ESBL resistance. Despite being asked on three occasions by the Social Services Designee about their preferred home health agency, the resident did not receive their choice of agency upon discharge. The Social Services Designee confirmed that they did not provide the resident with their choice of home health services because the preferred agency did not return calls. The designee did not follow up with the resident for an alternative choice and instead selected a home health service company themselves. This action was contrary to the facility's Transfer and Discharge Policy, which requires involving the resident in the development of the discharge plan and informing them of the final plan. This deficiency was investigated under Complaint Numbers OH00160628 and OH00160462.
Failure to Ensure Safe Discharge for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure a safe discharge for Resident #153, who had a history of type II diabetes mellitus, opioid dependence, and bipolar disorder. Despite being cognitively intact according to a BIMS score of 15, a subsequent evaluation using the Montreal Cognitive Assessment (MoCA) indicated moderate cognitive impairment, suggesting the need for a guardian. The resident expressed a desire to live with her son in New York, contrary to her daughter's wishes, who was the primary power of attorney (POA) and expressed concerns about the safety of this discharge. The facility's social worker had been in contact with the resident's son, who was listed as the third POA, and began discharge planning without adequately addressing the daughter's concerns or the psychological evaluation recommending a guardian. The resident's daughter was not informed of the discharge until after it occurred, and the facility did not contact adult protective services or the police, despite the daughter's concerns about potential harm. The Director of Nursing (DON) and other staff members were aware of the resident's desire to leave with her son and allowed the discharge against medical advice (AMA) to proceed, citing the resident's BIMS score. However, the facility did not fully consider the MoCA results or the daughter's request for a guardian, leading to a deficiency in ensuring a safe discharge process for the resident.
Failure to Assist Resident with Timely Transfer Referrals
Penalty
Summary
The facility failed to assist a resident, identified as Resident #22, in a timely manner with referrals for transfer, which was a deficiency found during the survey. Resident #22, who was admitted with diagnoses including multiple sclerosis, failure to thrive, weakness, chronic pain, and diabetes, expressed a desire to move closer to Ohio. Initial referrals were made, but there was a significant gap in follow-up and further assistance. The resident was cognitively intact, as indicated by a BIMS score of 15, and had been waiting for assistance with the transfer for several months. Interviews with the resident and the Social Services Director confirmed that while initial referrals were made, there was no evidence of ongoing discharge planning or assistance from January 26, 2024, to October 20, 2024. The Social Services Director acknowledged the lack of follow-up and confirmed that the resident had not been provided with a list of in-network nursing facilities from their insurance. This inaction was contrary to the facility's discharge planning notice, which stated that residents should be assisted in selecting a post-acute care provider in line with their goals and treatment preferences.
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.
