F0627

D

Failure to Ensure Safe and Coordinated Discharge for Homeless Resident Requiring Self-Catheterization

Charlotte, North Carolina Survey Completed on 01-28-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to implement an effective discharge planning process for a resident with benign prostatic hyperplasia causing urinary obstruction, homelessness, substance abuse, and cognitive communication deficits. The resident had been admitted from a hospital where he was treated for a urinary tract infection related to his enlarged prostate and was instructed to continue self-catheterization until a scheduled surgery. At admission, the resident was documented as moderately cognitively impaired and unable to make his own decisions, with a resident representative (RR) designated as decision maker. The RR informed the social worker (SW) that the resident had recently been evicted, was homeless, and that returning to the community was not feasible. The RR requested assistance with a Medicaid application and long-term placement closer to her, and the SW documented that discharge planning was ongoing and that the stay was expected to be short term.

Despite this, the admission MDS coded the resident as participating in discharge planning with an active plan for return to the community, and a key MDS question about discussing community discharge was skipped. The SW stated she notified the Business Office Manager that the RR requested Medicaid assistance but did not follow up to confirm that an application was submitted, and the Business Office Manager later reported no record of such a request or application. The SW also reported that a follow-up BIMS showed the resident cognitively intact but could not identify who completed it or when. During daily clinical meetings, therapy notified the SW that the resident’s skilled services were ending, and the SW then issued a CMS-10123 NOMNC letter explaining that Medicare Part A coverage would end. The SW stated she explained the appeal process and that the resident said he would not remain and would go to a homeless shelter, but the RR reported she was not informed of the right to appeal and was only told that the resident would be responsible for payment if he stayed.

The discharge planning notes documented that the resident would be discharged to a homeless shelter and that therapy recommended home health services for safety awareness, medication, and household management, but these services were not arranged because the discharge location and address were unknown. The SW did not contact the shelters the resident named to verify availability, and no safe discharge location was confirmed. The discharge instructions, completed by the SW and a nurse, indicated the resident had no devices or treatments and that no education or medical supplies were provided, even though the resident required self-catheterization and had a history of reusing catheters. The RR reported that at discharge she was only given medications and a medication list, with no catheter supplies or instructions, and that she later had to obtain catheter supplies from the urology office. The facility documented the discharge as against medical advice (AMA), completed an AMA form that the resident refused to sign, and the SW stated that an APS report was to be filed, but APS had no record of any report. The Medical Director and Administrator both stated that discharging the resident without arranged housing and needed medical supplies was not a safe discharge, and the Medical Director specifically noted that discharging the resident without housing and catheter supplies was not safe given his homelessness, variable cognition, and need for self-catheterization.

The SW indicated she did not know the resident was performing self-catheterization and believed nursing was responsible for reviewing discharge instructions and medications, but the assigned nurse could not recall whether instructions or supplies were provided. The SW also did not follow up with the RR or the resident after discharge and was unaware of his status. The RR stated that she had clearly informed the SW that local shelters were full and that the resident had no housing options, and that the SW offered no placement assistance other than stating the resident could remain at the facility only if he paid a daily rate. The RR further stated she was unaware that the discharge was labeled AMA and believed the facility initiated the discharge due to therapy ending. The Medical Director and Administrator were aware only that the discharge was categorized as AMA and did not recall details of the decision-making process. Collectively, these actions and omissions resulted in the resident being discharged without a verified safe destination, without coordination of recommended home health services, and without necessary medical supplies for his ongoing catheter care.

The facility’s documentation and interviews show multiple breakdowns in communication and follow-through related to discharge planning. The SW did not ensure that the RR’s request for Medicaid assistance and long-term placement was acted upon, did not verify shelter availability, and did not coordinate home health services due to lack of an address. The MDS documentation conflicted with earlier determinations that the resident could not safely return to the community, and a key discharge planning question was skipped. Nursing staff did not document or recall providing catheter supplies or education, and the discharge paperwork inaccurately indicated that the resident had no devices or treatments. The facility labeled the discharge as AMA and expected an APS report to be filed, but APS had no record of a report, and the SW did not verify that the report was made. These documented failures led to a discharge that did not ensure the resident’s needs were met, did not coordinate necessary services, did not identify a safe discharge location, and did not provide required medical supplies.