Failure to Ensure Safe and Appropriate Discharge Planning
Summary
A deficiency occurred when a resident with complex medical needs, including type 1 diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term insulin use, was discharged from the facility to a homeless shelter after residing there for over 22 years. The resident had a history of impaired vision, required supervision with insulin administration, and had documented deficits in adaptive functioning and executive skills. Despite these needs, there was no evidence of discharge planning, diabetic teaching, or preparation for self-care documented in the medical record prior to discharge. The resident was not provided with sufficient notice or preparation for the discharge, and there was no documentation of attempts to secure income, alternative housing, or necessary identification documents. The homeless shelter to which the resident was discharged did not have medically trained staff, only allowed a maximum 90-day stay, and had recently lost funding for programs that could assist with housing. Upon arrival, the resident lacked essential supplies such as insulin needles, which were only provided days later. The shelter staff and executive director expressed concerns that the resident lacked the life skills, income, and resources to care for himself and that the shelter was not an appropriate or safe discharge location. The resident missed a scheduled follow-up medical appointment due to lack of transportation arrangements, and interviews confirmed that he was unaware of the discharge plan until the day of transfer. Facility staff, including the DON and social services, confirmed that no discharge notice was provided to the resident or the Ombudsman, and that the discharge was prompted by insurance denial of payment for continued stay. Multiple interviews with staff, the resident, and external parties revealed that the discharge process was abrupt, lacked proper planning, and failed to ensure the resident's needs and preferences were met. There was no evidence of interdisciplinary team involvement or adequate preparation for the resident's transition to the community.
Removal Plan
- The Administrator immediately reviewed the last 30 days of discharges to ensure safe discharges occurred. No other areas of concern were noted.
- Follow up contact was made to Resident #83, #84, #85, #86, #87, and #88 who were discharged in the last 30 days. No concerns regarding discharge and no additional needs were identified by each resident.
- The Administrator immediately reviewed the pending discharges for Resident #16 and Resident #26 to ensure safe discharges plans with no other areas of concern noted.
- Social Services Director #180 and/or designee will notify the Ombudsman of the date the discharge notice is given.
- An in-service regarding the discharge process was completed by the Administrator with Social Services Director #180 that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Director of Nursing, Medical Director #275 and SSD #180 was held to review the discharge policy and procedure. No changes were made to the discharge policy and procedure at this time.
- The Facility Administrator was in-serviced by President of Operations #375 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- A full Intradisciplinary Team (IDT) meeting was held which included the Administrator, DON, SSD #180, Business Office Manager (BOM) #152, Assistant Director of Nursing (ADON) #166, and Activity Director #128 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A full house education was done by the Administrator and DON regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- Pending discharges will be discussed in the Stand-up Meeting daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday, with the IDT to ensure safe discharge plans and teaching or other needs. The IDT includes the following: Administrator, DON, ADON #166, BOM #152, SSD #180, and Activity Director #128. In the absence of one of these team members the other team members will act on their behalf.
- The Administrator, DON, or SSD #180 will notify Medical Director #275 of any pending discharge plans daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday.
- Pending discharge plans will be reviewed by the Administrator and/or designee and Director of Nursing and/or designee in Stand-up Meeting at least 3 times weekly for 6 weeks to ensure safe discharge plans have been made.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with quadriplegia, chronic pain, constipation, and anxiety was sent to an ER after reporting chest tightness and other symptoms, choosing transport to a different ER after declining the local ER. While the resident was out, housekeeping was asked to clean the room, but the resident declined multiple times, and the facility then decided not to readmit the resident. The record did not document the specific needs the facility could not meet or the attempts made to meet the resident’s needs before the readmission denial.
Staff incorrectly told resident representatives that transfers to a higher level of care would be treated as AMA discharges and that the residents could not return. One resident with a UTI, IV therapy, refusal of care, and repeated IV removal was sent to the hospital after the family requested transfer, and another resident was transferred for behavioral issues after the family had asked for acute care. In both cases, staff communications to the family and hospital incorrectly labeled the transfers as AMA.
A resident with anoxic brain injury, dementia, delusional disorder, and DM II was discharged without a completed discharge summary documenting medication or treatment instructions. The Administrator could not produce the completed summary, and the guardian reported no meds were sent home; instead, meds were called into a pharmacy in another city hours away.
A resident with CVA sequelae, DM2, epilepsy, wheelchair use, and assistance needs for transfers and ADLs was discharged to a hotel without a fully developed safe discharge plan. The discharge summary lacked details on transfer support, wound care, and transportation arrangements, and the DON confirmed no physician order was obtained and the summary was incomplete. After discharge, the resident fell while transferring from bed to wheelchair and was taken to the hospital.
Failure to provide involuntary discharge appeal notice: A resident with psychosis, schizoaffective disorder, epilepsy, TBI, dementia, and severe cognitive impairment was sent to the ED for psychiatric evaluation after escalating agitation and behavioral disturbances. The facility issued an involuntary transfer/discharge form stating it could not meet the resident’s needs and that the resident was unsafe for others, but there was no resident or RP signature, and the RP later said she was not told she could appeal or that the facility would not take the resident back.
A resident was transferred to the hospital for evaluation after a change in condition and was not re-admitted afterward. An admission staff member said the resident had been on hospice and that hospice would not take the resident back, but could not explain why the resident was no longer considered a facility patient or whether a bed was available. Family members reported the facility never contacted them about re-admission, despite the facility policy stating residents are to be allowed to return after hospitalization regardless of payer source.
Failure to Document Readmission Decision and Resident Needs
Penalty
Summary
The facility failed to document the specific needs it could not meet and the attempts made to meet a resident’s needs when it declined to readmit the resident after an acute care hospitalization. Resident #35 was admitted with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation, and anxiety. The resident had previously received a 30-day involuntary discharge notice for failure to pay, possession of marijuana, recording staff without consent, and violation of a behavior agreement, but that notice was later rescinded until an appropriate and safe alternative placement could be secured. On the day the resident reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort, the RN assessed the resident, obtained vital signs, and offered transfer to the local ER. The resident refused that option and chose to go to another ER, and the RN transported the resident there with paperwork. The resident was medically stable for transfer. While the resident was out of the facility, housekeeping was asked to clean the resident’s room, but the resident declined multiple times, which was noted as an infection control concern. An administrative decision was then made not to readmit the resident, and the justification for the notice of decision not to readmit was reviewed by the physician. Staff later confirmed the resident required catheter care and bowel care, had intermittent impulsive and verbally aggressive behaviors, and that the facility was able to meet the resident’s care needs.
Improper AMA Classification of Resident Transfers
Penalty
Summary
The facility failed to ensure that residents were allowed to return after requests to be sent to an acute care facility were honored, and staff incorrectly treated those transfers as Against Medical Advice (AMA) discharges. This deficiency involved two residents. In both cases, staff told the resident representatives that if the resident was sent out for a higher level of care, it would be considered AMA, even though the transfers were initiated by the facility or requested by the family and later carried out by the facility. For one resident, the record showed the resident was receiving IV fluids and antibiotics for refusal of medications, meals, and treatment for a UTI, and repeatedly pulled out the IV. The resident’s son insisted the resident be sent to the hospital so she could be restrained to keep the IV in place. Staff documented that the physician assistant did not want the resident sent out, and the son was told that sending her out would be AMA. The resident was then sent to the hospital due to worsening edema at the IV site, and the hospital later reported pneumonia, difficulty maintaining blood pressure, intermittent BiPAP use for shortness of breath, oxygen by nasal cannula while awake, and use of restraints for safety because the resident was combative. For the second resident, the family requested transfer to an acute care facility for behavioral issues, but was told the resident could be cared for in the facility and that sending the resident out would be an AMA discharge. Within a few hours, the resident was transferred anyway. The resident representative later reported being told by the hospital social worker that the resident was not allowed to return because of leaving AMA, although the resident had not left AMA. The administrator later confirmed the facility liaison told the acute care facility the resident could not return because the resident left AMA, and the corporate nurse stated the residents were not AMAs and that staff were confused.
Incomplete Discharge Medication Instructions
Penalty
Summary
The facility failed to ensure that a resident had access to medications upon discharge and did not complete the discharge summary with medication or treatment instructions. Resident #50 was admitted with diagnoses including anoxic brain injury, dementia, delusional disorder, and type II diabetes mellitus, and the discharge MDS indicated the resident was cognitively impaired. Review of the discharge summary showed only the social service section was completed, with no instructions provided to the resident or the guardian regarding medications and/or treatments. During interview, the Administrator stated the facility could not produce a completed discharge summary with medication or treatment instructions for the resident. The resident’s guardian stated she had been given instructions, but no medications were sent home with the resident and the medications were called into a pharmacy located in another city hours away. The facility policy required discharge information to include a recap of the resident’s stay and reconciliation of pre- and post-discharge medications.
Unsafe discharge planning and incomplete discharge documentation
Penalty
Summary
The facility failed to ensure Resident #86 was discharged appropriately. The resident was admitted with diagnoses including unspecified sequelae of cerebral infarction, type 2 diabetes mellitus with hyperglycemia, and epilepsy. The resident had a BIMS score of 14, used a wheelchair, had one-sided range-of-motion limitations in the upper and lower extremities, and required assistance or supervision with multiple activities including eating, hygiene, dressing, toileting, transfers, and walking short distances. The care plan stated the resident was to discharge into the community once an appropriate setting was found, and social service notes documented that there was still no community discharge recommendation and no safe discharge plan due to lack of family support and the resident’s unwillingness to pursue potential sources of income. The resident was discharged to a hotel with medications and appointment instructions, but the discharge summary did not identify services to assist with wheelchair transfers, did not specify the wound care needed, and did not state whether the resident could independently arrange transportation to appointments. The DON confirmed a physician order was not obtained before discharge and that the discharge summary was not fully completed and lacked the resident’s signature. The Administrator stated the facility arranged and paid for the hotel room and transportation, provided a gift card, and gave the resident a check from his account. The SSD later reported that the resident fell while transferring from the bed to the wheelchair at the hotel and was taken by emergency services to the hospital, where he remained as of the last review.
Failure to Provide Involuntary Discharge Appeal Notice
Penalty
Summary
The facility failed to provide notification of involuntary discharge that included information about the resident’s right to appeal for one resident reviewed for admission, transfer, and discharge. The facility policy stated that transfer/discharge notices must be provided in a language and manner the resident and representative can understand and must include appeal rights and state contact information. The policy also stated the notice must generally be provided at least 30 days before transfer or discharge, with exceptions for certain urgent circumstances. Resident #29 was admitted with diagnoses including psychosis, schizoaffective disorder, anxiety, epilepsy, traumatic brain injury, and dementia. The record showed a significant change MDS with a Brief Interview for Mental Status score of 00, indicating severe cognitive impairment, along with daily behaviors toward self, dependence on staff for ADLs, and use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. On 7/6/2026, the physician ordered the resident sent to the ED for immediate evaluation due to increased agitation and escalating behavioral disturbances that presented an immediate risk of harm to herself and others, and the resident was transferred to the ER for a psychiatric evaluation. The Nursing Home Notice of Involuntary Transfer or Discharge form dated 7/6/2026 listed reasons for discharge or transfer, including that the nursing home could not care for the resident and that the resident made the nursing home unsafe for other people. The form was signed by the Administrator and Medical Director, but there was no signature from the resident or responsible party. The resident’s responsible party later stated she was unaware she could appeal and reported that the facility did not tell her it would not take the resident back. During interview, the Administrator stated the responsible party was contacted, the situation was explained, and the notice was mailed, but the facility was unable to provide a signed copy of the notice showing that appeal information had been provided.
Failure to Re-Admit Resident After Hospital Transfer
Penalty
Summary
The facility failed to re-admit a resident after the resident was sent to a hospital for evaluation due to a change in condition. During record review, staff confirmed that the resident was transferred to the hospital and was not re-admitted to the facility afterward. An admission staff member stated the resident had been under hospice care before the transfer and explained that when the hospital called to arrange re-admission, hospice would not take the resident back. The staff member further stated the resident was a hospice patient and not a patient of the facility, but did not provide an explanation for how the resident was no longer considered a facility resident. During interviews, the admission staff member did not explain whether there were available beds or whether the resident was placed on a wait list. The resident’s record showed three family members/emergency contacts, and all three family members stated the facility never contacted them regarding re-admission. The facility’s Bed-Holds and Returns policy stated that residents are to be permitted to return to the facility following hospitalization or therapeutic leave regardless of payer source, and that residents seeking to return within the bed-hold period are allowed to return to their previous room if available.
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