F0627

D

Failure to Readmit Hospitalized Resident and Follow Bed-Hold/Discharge Policies

Battle Creek, Michigan Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to allow a hospitalized resident to return to the facility at the first available bed and failure to follow required transfer, bed-hold, and discharge policies and procedures. The resident was an adult male with a progressive neurologic disorder, dementia with agitation, and an adjustment disorder with anxiety. His MDS showed a BIM score of 9, indicating moderately impaired decision-making, with limited documented behavioral symptoms prior to the events in question. He had been admitted to the facility in October and was later transferred to the hospital due to exit-seeking behavior and difficulty with redirection, but his care plans and orders were discontinued on 1/19/26 even though he had not been formally discharged through the required process.

Prior to the final hospital transfer, the resident had episodes of exit-seeking and was placed on 1:1 supervision for safety. Documentation on 11/14/25 showed that he was readmitted from a local hospital with a diagnosis of dementia and placed on 1:1 supervision due to exit-seeking behavior. An elopement evaluation on 11/14/25 documented wandering behaviors that were likely to affect his safety, and he was identified as recently admitted and not yet accepting the situation. Subsequent nursing notes from 11/14/25 through 12/27/25 reflected no documented behaviors and described him as pleasant, cooperative, and continuing on 1:1 supervision. On 12/27/25 and 12/28/25, three notes documented increased agitation, exit-seeking, and physical aggression toward staff, and the provider was contacted after failed attempts at redirection. The resident was then transferred to the hospital on 12/28/25.

After this transfer, the facility did not provide evidence that a required Transfer Notice or Bed Hold policy information was given to the resident or his representative. Interviews with the SW and DON confirmed uncertainty or lack of knowledge about whether these notices were provided, despite facility policy requiring written information before transfer and permitting residents to return after hospitalization. The DON acknowledged that the resident had been gone longer than the 10‑day bed-hold period and that the guardian had declined to pay to hold the bed, but also confirmed that the facility census was 62 with at least 72 beds available and that the resident’s prior bed had remained empty from 12/28/25 to the survey date. The BD stated that the clinical team decided the resident would not be allowed to return due to aggressive behaviors and that his bed had been “spoken for,” while also acknowledging that the only male bed on the unsecured unit was promised to another resident after the psychiatric hospital had already been told there were no beds available for the resident.

The psychiatric hospital case worker reported contacting the facility on 1/19/26 to inform them the resident was ready to discharge back, less than 30 days after admission, and was told there were no beds available and that a list of other placement options would be provided. The Ombudsman reported prior communication with the facility about concerns regarding an appropriate discharge for the resident and stated that the resident had reported being threatened with not being allowed to return, even though no involuntary discharge process had been initiated. The facility’s own Bed Hold and Return to Facility policy required that residents be allowed to return to their previous room if available, or to the first available semi-private bed, and that if the facility determined a resident could not return, it must comply with transfer and discharge requirements. The surveyor observed multiple open beds, including the resident’s prior room being empty, and the bed board showed additional available beds, some reserved for Medicare and others offline, while the resident, a Medicaid recipient, remained hospitalized without being readmitted. These actions and omissions resulted in the facility failing to permit the resident’s return at the first available bed and failing to implement required discharge policies and procedures, creating increased likelihood of anxiety, stress, and uncertainty about placement for the resident.