F0627

D

Failure to Honor Return Rights and Complete Required Discharge Procedures

Chicago Ridge, Illinois Survey Completed on 01-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to return following hospitalization and to conduct proper discharge procedures. An older adult resident with vascular dementia, documented as cognitively intact with a BIMS score of 14/15 and described in an 8/31/2025 psychiatric evaluation as pleasant, calm, cooperative, and without behavioral issues, was transferred to the hospital on 9/29/2025 after exhibiting agitation and did not return. On interview, the DON stated that she and the Administrator decided not to allow the resident to return due to behavior concerns. The facility was unable to provide any physician assessment determining that the resident could not be safely cared for in the facility, and the resident’s primary physician confirmed he had not seen the resident and had no record of evaluation. No documentation was provided showing a psychiatric reassessment following the behaviors cited by the facility, and there was no change in condition noted in the resident’s medical record.

Record review revealed no written discharge notice, no discharge planning documentation, and no evidence that the resident or representative was informed of appeal rights. When surveyors requested any and all documentation or assessments used in determining the resident’s involuntary discharge, none were provided. This failure occurred despite facility policies stating that the facility would adhere to federal regulations on bed hold and readmission, including permitting residents transferred for hospitalization to return to the first available bed after exceeding the bed hold period, and that proper discharge planning and instructions would be conducted once a discharge order is obtained from the attending physician.