Failure to Document Basis, Notification, and Planning for Resident Transfer/Discharge
Summary
The deficiency involves the facility’s failure to properly document and justify a facility-initiated transfer/discharge, to adequately notify and involve the resident’s representatives, and to complete required discharge planning and summaries for a resident with severe dementia. The resident was an elderly female with unspecified dementia with agitation, unspecified dementia with behavioral disturbance, and major depressive disorder. Her annual MDS showed a BIMS score of 06, indicating severely impaired cognition, and documented non‑Alzheimer’s dementia and depression treated with antidepressants. Despite her cognitive impairment, she was independent in self‑care and mobility, and the MDS and a recent QRR summary indicated no verbal or physical behaviors directed toward others in the prior week. Her care plan documented dementia, safety/security issues, and placement in a secure memory care unit, and later revisions noted a history of aggression related to roommate situations and prior resident‑to‑resident altercations, but also that she did not currently have a roommate. Social service documentation showed that the LMSW contacted one family member (identified as a resident representative and POA) about “solutions” for a recent incident with another resident and that this family member stated she would be okay with a facility closer to her if it came to that alternative to give the resident more room to move around. However, the clinical record from admission forward contained no documentation of a valid regulatory basis for discharge. The discharge summary completed by the DON listed the reason for discharge as requiring a locked unit that allows more space to move around and indicated discharge to another staffed facility, but the physician signature and date lines were not completed. There was no evidence in the record of a written notice of transfer/discharge with reasons for the move, no 30‑day notice, and no documentation that the POA(s) were notified in advance of the actual transfer. The LMSW later sent an email to one POA after the transfer had already occurred, providing the name, address, and contact information of the receiving facility and describing it as a larger locked facility with more space and activities. Email correspondence between the LMSW and both POAs after the transfer reflected disagreement about whether consent for the move had been given. One POA wrote that she had only agreed to consider a move closer to her, denied agreeing to the suggested facility, and stated that incidents were not discussed at the time. The LMSW responded that he interpreted her statement (“if we have to move her then I guess we have to”) as agreement to transfer if needed. The second POA stated in a phone interview that she did not know why the resident was transferred, believed prior incidents had been handled and the resident was stable, and reported that the decision to move seemed abrupt. She stated she was contacted by the new facility’s admissions coordinator about transfer arrangements before she was aware of any approved transfer and that she told both the admissions coordinator and the LMSW she did not approve the move, yet the resident was transferred the next day. The nursing progress note documented that the resident left the facility via wheelchair with clothing and medications given to transport personnel, but the record contained no documentation of sufficient preparation and orientation of the resident for a safe and orderly transfer, no evidence of an effective discharge planning process involving the resident and both resident representatives, and no discharge summary that included a post‑discharge plan of care developed with the participation of the resident representative(s), as required by facility policy and regulation. In interviews, the LMSW stated he was responsible for the transfer/discharge process, which should include discussing the transfer with the resident or POA, obtaining agreement, providing written notice, and, if there was disagreement, issuing a 30‑day discharge notice with appeal and Ombudsman information. He acknowledged that he notified one POA on a specific date that the resident would benefit from more space and that he believed she initially agreed to locating another facility. He also acknowledged that the transfer occurred very quickly, that his email notification to the POAs and Ombudsman went out after the resident had already been transferred, and that this was not the facility’s usual practice. He stated he was under pressure to get the resident transferred and that the DON’s relationship with the receiving facility expedited the process. The administrator stated the facility followed its discharge/transfer policy, but record review showed no documented basis for discharge, no documented prior notification to the POAs, no documented discharge planning process involving the resident and representatives, and no post‑discharge plan of care, contrary to the written policy that required individualized discharge planning, written notice for facility‑initiated non‑emergent transfers, and a post‑discharge plan of care. The facility’s own policy on Discharge or Transfer required that the discharge planning process address each resident’s discharge goals and needs, involve the resident and resident representative and the interdisciplinary team, and that for facility‑initiated non‑emergent transfers or discharges, the facility provide written notice to the resident and representative(s) with reasons for the move at least 30 days in advance, and send a copy to the State LTC Ombudsman. The policy also required a post‑discharge plan of care detailing arrangements made to address the resident’s needs after discharge and instructions given to the resident and representative. Review of the resident’s clinical record from admission onward showed no documentation that these policy requirements were met: there was no valid basis for discharge documented, no evidence of timely written notification to the POAs, no documentation of sufficient preparation and orientation for the resident, no evidence of an implemented and effective discharge planning process involving the resident and both resident representatives, and no discharge summary including a post‑discharge plan of care.
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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