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