Failure to Ensure Safe and Appropriate Discharge Planning
Summary
A deficiency occurred when a facility failed to ensure a safe and appropriate discharge for a resident with a complex medical and psychiatric history, including epilepsy, encephalopathy, anxiety disorder, and schizophrenia. The resident had fluctuating capacity to make medical decisions, was at risk for falls, and required assistance with ambulation, medication management, and activities of daily living. Despite these needs, the resident was discharged to an unlicensed board and care (B&C) facility that could not provide the necessary level of care, including ambulation assistance, epilepsy management, or medication administration and storage. The facility did not follow its own discharge and transfer policy and procedures, as the interdisciplinary team (IDT) did not conduct a discharge planning meeting prior to the resident's transfer. Key departments, including nursing, activities, and rehabilitation, were not notified or involved in the discharge planning process. The resident's care plan, which required coordination with rehabilitative therapies and community resources, was not implemented, and the discharge planning review form was incomplete. The facility also failed to verify the B&C's license, assess the appropriateness of the discharge location, or provide a hand-off report to the receiving facility regarding the resident's medical conditions and care needs. As a result of these failures, the resident experienced a series of adverse events after discharge, including a fall with head injury at the B&C, subsequent hospitalization, transfer between multiple facilities, and an episode of elopement that led to police intervention and further hospitalization. Interviews with facility staff and external providers confirmed that the resident's needs exceeded the capabilities of the B&C, and that critical steps in the discharge process, such as medication reconciliation, communication with the receiving facility, and post-discharge follow-up, were not performed.
Removal Plan
- The Social Services consultant initiated an educational in-service to licensed nurses and IDT regarding facility Discharge and Transfer policy and procedures. In-service included Surrogate Decision Maker-Informed Consent, Discharge and Transfer of Residents, Personal Representatives of Residents, Resident Rights, Treating Residents Without Decision-Making Capacity, Conducting IDT prior to discharge, and the importance of initiating discharge planning prior to discharge or transfer of a resident. In-service education is ongoing by the facility's Director of Nursing (DON)/Director of Staff Development (DSD)/Designee including the new processes implementation related to identified concerns to all active license nurses and IDT members.
- The facility has 30 licensed nurses and 24 have been provided with in-service and education. Facility does not have a licensed staff on vacation, leave nor FMLA (Family and Medical Leave Act).
- The Social Services consultant worked 1:1 with the Social Services Director (SSD). The SSD completed the Discharge Planning Review form, sections 1 (Discharge Goals/ General Information) A (Discharge Goals/ General Information) & B (Caregiver Responsibilities), 2 (Self Care Evaluation and Equipment) Q (equipment and supplies), Contacts and Sign and Date of the Discharge Summary, for training purposes.
- The facility DON and Medical Records initiated an audit to residents who have been discharged to a lower level of care in the past 30 days to ensure proper discharge planning was conducted prior to discharge with resident/responsible party, an IDT meeting was conducted prior to discharge, an endorsement of the resident's medical history and medication reconciliation was provided to receiving facility. No similar issues were identified.
- For those residents who lack capacity or with fluctuating capacity, the Office of Public Representative (OPR) will be contacted by the facility's SSD/Designee to act as an advocate in the discharge plan IDT prior to the discharge to ensure location is safe and appropriate given the residents' conditions. If the OPR does not wish to participate, the facility IDT in conjunction with the physician will hold an IDT meeting to review and document appropriateness.
- For those residents who lack capacity or with fluctuating capacity and have resident representatives, an IDT meeting will be held with the responsible party to review and discuss the discharge location for safety and appropriateness.
- Discharge planning will begin on the residents' admission to the facility.
- The Attending Physician and the IDT will review the residents' progress and determine a possible discharge date and document in resident's health record.
- The facility Admin notified Resident 1's attending physician, by phone of the concerns related to the resident's transfer to the Board and Care, the fall sustained and readmission to the hospital.
- The facility Admin notified facility Medical Director by phone of the Immediate Jeopardy that was issued, deficient practice and plan to correct.
- The facility Admin initiated a QAPI (Quality Assurance and Performance Improvement) regarding the Transfer and Discharge of residents.
- The facility staff will assist the physician and the resident to obtain medications after discharge from the facility. When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge if the medications were specifically ordered to be sent home with the resident.
- The Licensed Nurse will assure that the medication orders are reviewed with the resident and/ responsible party and explanation of all discharge medication orders occur at the time of discharge and documented on the resident's health record.
- The facility will ensure that the resident receives adequate follow-up including the ability to have a physician's prescription available to procure drug supply immediately after discharged from the facility and conduct a proper endorsement of resident's ordered medications and discharge instructions to the receiving facility and documented on the resident's health record.
- The facility's SSD and Admin located Resident 1. Resident 1 resided in Skilled Nursing Facility (SNF) 2 and was doing well.
- The facility's SSD/Designee will conduct a post discharge follow up call within 72 hours to ensure that the resident has transitioned adequately to the new facility/location moving forward.
- Newly hired licensed nurses/IDT will be educated by the facility's DON/DSD on facility's P&P pertaining to Discharge and Transfer of residents during their orientation and as needed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic pain and a left below-knee amputation, who required supervision or touching assistance with ADLs, was discharged after returning from an outing shortly after midnight. Although discharge instructions noted the need for assistance and assistive devices, there was no documentation of referrals for medical equipment or home health services. Facility staff documented that the resident was discharged because they were out past midnight and believed Medicare would not cover the stay, did not issue a NOMNC, and recorded the discharge as voluntary despite the resident later reporting they had been “kicked out” and were sleeping on a friend’s couch with difficulty getting around. Staff interviews revealed no financial issues and indicated the resident had originally been scheduled for discharge at a later date.
Staff failed to follow the facility’s emergency transfer/discharge policy when they discharged a resident to a local hospital for safety reasons and refused to allow the resident to return. The resident had been in the facility less than 24 hours, refused care, and made threats that scared staff, leading the administrator to authorize an immediate emergency discharge. Documentation included a progress note and an Immediate Discharge Notice listing the hospital as the discharge location for resident and staff safety, despite the administrator acknowledging that a hospital is not an appropriate discharge location. These actions resulted in the resident being discharged to a hospital without an appropriate emergency discharge notice that ensured the transfer met the resident’s needs/preferences and prepared the resident for a safe transfer/discharge.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
A resident with dementia, severe cognitive impairment, and total ADL dependence was under a 30‑day discharge notice indicating his needs could not be met and listing his home as the discharge location, later amended to allow earlier transfer to a memory care facility. After the resident exhibited increased agitation, wandering, and unsteady gait, an RN obtained an order to send him to the ER, where he was medically cleared the same day and documented as not an imminent threat. When the hospital attempted to return him, the DON refused readmission due to safety concerns, despite the Regional Ombudsman’s communication that the facility was obligated to readmit him unless the family chose direct transfer to memory care. Email exchanges show the Administrator and DON maintained that the facility could not take him back, resulting in the resident remaining in the ER for several days before being discharged home with family and later placed in another memory care setting.
A resident with hemiplegia and dependence for transfers was discharged home without effective discharge planning or documentation. The care plan called for coordinated discharge orders, home health and therapy referrals, and DME, but social services did not clearly assist with the insurance appeal process, did not document a comprehensive discharge plan, and did not arrange post‑discharge services. The family member reported receiving short‑notice of discharge, no caregiver education, no referrals for home health or outpatient therapy, and no help obtaining needed DME such as a wheelchair and hospital bed. Nursing staff were unaware of the exact timing of discharge and the ambulance left without the printed discharge paperwork. Therapy staff were not informed in time to complete a discharge assessment and stated the resident remained dependent with transfers and unsafe to stand. The discharge packet later found in a shred box was incomplete, lacking transportation details, instructions review, signatures, and key contact information, demonstrating that the resident was discharged without a safe, orderly, and well‑documented transition plan.
A resident with multiple chronic conditions, intact cognition, and a history of depression and anxiety was involuntarily discharged to a homeless shelter after an episode of verbal aggression toward staff. The facility had previously issued unsigned 30‑day and same‑day involuntary discharge notices naming the shelter as the destination. On the day of discharge, an LPN reported the resident blocked her and threatened her during medication administration, the administrator called police, and the resident was ultimately removed in handcuffs. Staff interviews confirmed that no physician was notified, no physician order or updated assessment was obtained, and no comprehensive discharge summary, medication reconciliation, or post‑discharge plan of care was completed with the resident, despite facility policy requiring these steps for transfer/discharge, especially when behavior is cited as endangering safety. The Ombudsman was not notified of the discharge or police involvement, and there was no documented evidence that the resident was adequately prepared or oriented for a safe and orderly discharge.
Failure to Ensure Safe and Orderly Discharge After Late Return from Outing
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a resident who was admitted with chronic pain, a left below-knee amputation, and post-surgical aftercare needs. An admission MDS completed shortly after admission documented that the resident was cognitively intact but required supervision or touching assistance with toileting, transfers, and bathing. Discharge instructions indicated the resident was being discharged home and that the resident’s current physical status required assistance and assistive devices, yet there was no documentation of referrals for needed medical equipment or a home health referral. The facility’s records did not show that these services or equipment were arranged prior to discharge. On the night in question, a nursing note documented that the resident returned to the facility after an outing at 12:23 AM, after the facility had notified the police because the resident’s location was unknown. The resident reported having been out with friends and being unaware of any concern. A social services note stated that because the resident was out past midnight, the resident was discharged from the facility, and a NOMNC was not issued because the resident left prior to the scheduled discharge and on their own initiative. A discharge summary documented that discharge instructions were reviewed with the resident, who refused to sign and was leaving voluntarily, and the voluntary consent form included a handwritten statement that the resident refused to sign. Later, the resident stated they had been “kicked out” for coming back late and were sleeping on a friend’s couch, finding it difficult to get around. Staff interviews showed there were no financial issues documented, that staff believed Medicare would not cover the resident if out past midnight, and that the resident had been scheduled for discharge several days later, while a regional director later characterized the situation as a clerical error and confirmed a normal discharge should have been completed.
Improper Emergency Discharge to Hospital and Refusal to Readmit Resident
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice and improperly discharged a resident to a hospital while refusing the resident’s return. The facility’s policy on making an emergency transfer or discharge, revised April 2007, directed staff to only make an emergency discharge when it is in the best interest of residents and to follow specific procedures, including notifying the attending physician and receiving facility, preparing the resident and a transfer form, notifying the representative and family, and assisting with transportation. Record review showed the resident was admitted on 3/3/26 and discharged to the hospital the same day, with a progress note the following day documenting an emergency discharge effective immediately to the local hospital for safety reasons. An Immediate Discharge Notice dated 3/3/26 listed the local hospital as the discharge location for resident and staff safety. In an interview, the administrator stated the resident had been in the building less than 24 hours, had refused care, made threats, and scared staff, and that an emergency discharge to the hospital was done that day; the administrator acknowledged that a hospital is not a discharge location but stated the facility would not take the resident back for the safety of staff and other residents. These actions and documentation show that staff used the hospital as the discharge location and refused readmission, contrary to the facility’s own emergency transfer/discharge policy and without providing an appropriate emergency discharge notice that ensured the transfer/discharge met the resident’s needs and preferences and prepared the resident for a safe transfer/discharge.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
Failure to Readmit Hospitalized Resident Under 30‑Day Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to readmit a resident after a hospital transfer while the resident was under a 30‑day discharge notice. The resident had dementia with behavioral disturbances, dysphagia, and chronic kidney disease, was severely cognitively impaired, and required staff assistance with all ADLs. The admission MDS indicated no coded behaviors and documented that the resident wished to remain in the facility long term. Care plans created earlier in the month identified the resident’s need and preference for long‑term care placement and documented risks for wandering and elopement, with interventions such as purposeful activities, de‑escalation strategies, and reorientation. On 2/26, the facility issued a 30‑day discharge notice stating that discharge was necessary for the resident’s welfare and that his needs could not be met in the facility, listing his home address as the discharge location. A revised notice the same day added a handwritten note that discharge could occur sooner if appropriate placement was found at a named memory care facility, while still listing the home address as the discharge location. The resident’s family reported that the memory care facility that assessed the resident was not acceptable to them, and they were working to find another placement. Despite this, the 30‑day discharge notice remained in effect. On 2/28, Nurse #5 documented that the resident had increased confusion, agitation, wandering, unsteady gait, and was at one point falling into the wall while walking. The nurse reported that the resident attempted to swing at staff, contacted the medical provider, obtained an order to send the resident to the ER, and notified the responsible party. Hospital records show the resident was brought to the ER for abnormal gait and increased agitation and was medically cleared for discharge later that day, with documentation that he was not an imminent threat to himself or others. When the hospital attempted to return the resident to the facility, the Former DON told the Hospital Case Manager that the resident would not be returning due to safety concerns and documented that the Regional Ombudsman was involved. Email communications among the social worker, Administrator, Former DON, and Regional Ombudsman show that the social worker sent the amended 30‑day discharge notice to the Ombudsman on 2/28 after the resident’s transfer. The Regional Ombudsman later relayed that the Hospital Case Manager reported the resident was in the ER, not admitted, and that unless the family chose to move him directly to memory care, the facility was obligated to readmit him and provide a sitter until transfer. The Administrator acknowledged that the resident had been accepted to memory care and that the family was considering options, and later indicated that the family wanted to appeal the 30‑day discharge notice. When the Ombudsman asked if the resident would return to the facility, the Administrator suggested he would, but the Former DON responded that the facility was not able to take him back. Hospital records and interviews confirm that the resident remained in the ER from 2/28 until 3/6 because the facility would not readmit him while the 30‑day discharge notice was in effect. The Hospital Case Manager stated that when the facility was contacted on 2/28 to readmit the resident, the Former DON refused. The Regional Ombudsman stated she informed facility management of the resident’s right to return and that the Former DON maintained the facility would not readmit him. The resident was ultimately discharged from the hospital to his home with a family member and later placed in another memory care facility. These actions and inactions demonstrate that the facility did not ensure the resident’s transfer and discharge were consistent with his needs and preferences and did not readmit him after hospital evaluation despite his being medically cleared and under an active 30‑day discharge notice.
Failure to Conduct and Document Safe, Coordinated Discharge Planning to Home
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure a safe and orderly discharge for one cognitively intact resident who was dependent for transfers and required extensive assistance. The resident had diagnoses including aftercare following joint replacement, an artificial left knee joint, and hemiplegia/hemiparesis following a cerebral infarction affecting the left dominant side. His care plan identified him as a short‑term stay resident with good discharge potential and included interventions such as coordinating physician orders for discharge, arranging home health and equipment, evaluating discharge potential, and ensuring discharge to a safe environment with ongoing services. Despite these documented expectations, the facility did not carry out the planned interventions or document a comprehensive discharge needs assessment and plan in the medical record. On 2/20, the business office and MDS staff received notice that the resident’s last covered day would be 2/22, and the resident was served a Notice of Medicare Non‑Coverage, which he signed. The social services staff member, who was new and minimally trained, believed the resident’s signature only confirmed understanding of appeal rights and did not recall discussing specific discharge plans, in‑home services, or outpatient therapy with the resident or his family. The family member reported believing that signing the form constituted an appeal and attempted to contact the insurer, but later learned the appeal had not been properly initiated. The facility’s business office manager discussed private‑pay costs with the family member and stated that, because there was no appeal on record, the resident would have to discharge or pay cash. The family member reported that social services did not assist with understanding or initiating the appeal process, despite the facility policy stating that residents would not be discharged while an appeal was pending and that social services would assist with appeals. On the day of discharge, the family member was notified that the resident would be leaving within about an hour, expressed anxiety about the discharge, and reported not having transportation arranged. She requested to borrow a wheelchair and was denied any assistance from the facility. She then packed the resident’s belongings, called an ambulance, and left to prepare the home, arranging for neighbors to help when the resident arrived. Nursing staff reported that an LPN took over care shortly before the end of her shift, was told the resident was packed and ready to discharge, and did not have any discharge conversations with the resident or family; she later learned from a CNA that the resident had already left and documented that the ride did not receive the printed discharge paperwork. Therapy staff stated they were not informed in time to complete a discharge assessment or plan, and that the resident remained dependent with transfers and not safe to stand, with no discussions about the family’s ability to care for him at home. The discharge packet later found in a shred box contained incomplete documentation, including blank sections for method of transportation, discharge instructions review, staff and resident signatures, and contact information, and there were no progress notes documenting discharge discussions beyond a single note about the family’s anxiety. The family member reported receiving no caregiver education, no referrals for home health or outpatient therapy, and no assistance obtaining DME, and stated it took about a week after discharge to obtain a wheelchair and hospital bed while the resident remained in bed at home. The facility’s written policy required that staff work with the physician to obtain adequate documentation for discharge, provide preparation and orientation to the resident and family, assist with appeals, and document the resident’s health status, discharge needs, and discharge plan, including services to be provided after discharge. It also required that residents not be discharged while an appeal was pending and that appropriate education and instructions be provided for a safe care transition. In this case, the NP’s last visit note did not mention discharge, and the recapitulation of stay and discharge documents lacked key clinical and contact information, special instructions, and confirmation that instructions were reviewed with the resident or representative. Interviews with the DON and other staff confirmed that social services were responsible for the discharge process and documentation, yet the record contained almost no documentation of discharge planning, no evidence of coordination of home services or DME, and no evidence that the resident and family were adequately prepared or oriented for discharge. These actions and omissions resulted in the resident being discharged to the community without a confirmed capable caregiver in place and without necessary DME available at the time of discharge.
Failure to Assess, Notify Physician, and Plan Safe Discharge Before Involuntary Removal to Homeless Shelter
Penalty
Summary
The deficiency involves the facility’s failure to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one resident. The resident had multiple significant diagnoses, including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair. The MDS showed the resident was receiving opioid pain medication, antiplatelet medication, insulin, and anticonvulsant medication, and had an intact BIMS score of 15/15 with no documented behavioral symptoms toward others. The resident’s care plan included monitoring and documenting any risk for self-harm and signs and symptoms of depression, such as hopelessness, anxiety, sadness, and impaired judgment or safety awareness. The facility issued an involuntary discharge notice on facility letterhead in February, citing endangerment to the safety of individuals in the facility and identifying a homeless shelter as the discharge destination, with an effective and expected transfer date one month later; this notice was unsigned. A second involuntary discharge notice, also unsigned, was issued in March, again citing the same regulatory authority and naming the same homeless shelter as the discharge destination, with the effective and expected transfer date on the same day. On the day of the March discharge, a progress note documented that an LPN attempted to administer medications and offer a pain pill, after which the resident became verbally aggressive, yelled, cursed, threatened the nurse, and blocked her between the meal tray cart and the med cart. The resident eventually moved his wheelchair, the nurse left, and the administrator was notified; the administrator then called the police, who came to the facility, spoke with the resident, and recommended discharge. The resident was given time to pack belongings, and the social worker and nurse attempted to provide discharge paperwork, which the resident refused to sign while continuing to yell. Staff interviews revealed that nursing staff did not notify the physician about the discharge, and the social service director and administrator both confirmed that the physician was not notified. The social service director stated she had been working on transferring the resident since the fall, that the resident had multiple denials for placement, and that he had previously lived in a shelter before admission and lost his leg after an infection. She reported being instructed to give discharge papers to the homeless shelter, that the resident refused to sign, and that the administrator called the police due to the resident’s verbally aggressive behavior. The administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the State Agency or Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician but was unsure what a recapitulation of stay entailed. The facility’s own transfer and discharge policy required, in situations where a resident’s clinical or behavioral status endangers safety, physician documentation of the reason for transfer or discharge, a physician’s order for transfer or discharge, and completion of a discharge summary including a recap of the stay, final status, medication reconciliation, and a post‑discharge plan of care developed with the resident. These required assessments, notifications, and discharge planning elements were not completed or documented for this resident’s discharge to a homeless shelter following police removal from the facility. Additional information from the Ombudsman and external records further described the circumstances surrounding the discharge. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out because he allegedly pushed a pregnant staff member, which he denied, and that police had been notified; the Ombudsman also stated the facility had not reported the incident, police action, or discharge to the Ombudsman office, although a prior incident involving the resident hitting another resident had been reported the previous summer. A county sheriff’s inmate listing documented that the resident was booked for trespass on the same day as the discharge and released the following day. The administrator later stated she did not know the resident’s whereabouts after learning that another resident’s family member had picked him up after police release and taken him to the hospital, from which he was then discharged. Throughout these events, there was no documentation of an updated assessment, physician involvement, or a comprehensive, resident‑involved discharge plan as required by facility policy and regulation, nor evidence that the resident was adequately prepared or oriented for a safe and orderly discharge to the identified homeless shelter.
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