F0627

D

Failure to Plan and Document Safe, Destination-Specific Discharges for Two Cognitively Impaired Residents

Brenham, Texas Survey Completed on 01-20-2026

Penalty

Fine: $25,500

Summary

The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for two cognitively impaired residents prior to transfer/discharge, and to ensure they were discharged to a known, appropriate provider with adequate clinical information. One resident, a 74‑year‑old female with schizoaffective disorder, bipolar type, CHF, and major depressive disorder, had a BIMS score of 8 indicating moderate cognitive impairment. Her care plan, initiated in December and last revised in early January, contained no discharge planning. The other resident, an 82‑year‑old male with dementia, traumatic subdural hemorrhage, and paranoid schizophrenia, had documentation indicating he was severely cognitively impaired (BIMS summary score 99) and rarely/never understood, yet his care plan also reflected no discharge planning. For both residents, the facility’s discharge instruction forms dated the day of transfer were blank, with no information or questions completed.

For both residents, the transfer/discharge reports were incomplete and inaccurate, and did not clearly identify the discharge destination or provide key clinical information. The transfer report for the first resident listed a transfer to a nursing home but did not record the name of the facility and omitted behavior, ambulation, bladder, bowel, and feeding information. The transfer report for the second resident listed a transfer to an acute care hospital, omitted a primary contact, and also lacked behavior, ambulation, bladder, bowel, and feeding information. Physician telephone orders for both residents only stated they “may transfer to another facility,” without specifying the receiving provider. Progress notes for the first resident documented that she was discharged by wheelchair van in stable condition with medications and that discharge instructions were reviewed, but there was no documentation of the actual receiving facility. The administrator later documented speaking with an emergency contact about the resident’s “location” and noted that messages had been left for the resident’s RP regarding the transfer, but there was no evidence of a completed discharge plan or clear destination.

Interviews and additional record review showed that both residents were in fact discharged into the care of a non‑profit placement agency rather than directly to a known SNF or group home, and that the RPs were not clearly informed of the discharge destination at the time of transfer. The executive director of the placement agency stated she told the facility she would take both residents to a hospital for evaluation and then find placement depending on their needs, and that she informed the facility both residents were going to the hospital. She reported that one resident had a mental health episode while in her care, resulting in police involvement and transfer to a hospital for emergency mental health services, and that the other resident was moved between group homes after an initial one‑day stay. She also stated that both residents were discharged with medications, but one resident left with only the clothes he was wearing and neither resident had personal belongings. The DON and ADM gave conflicting accounts of the type of setting to which the residents were sent, with the ADM describing it as a personal care home and the DON stating she thought it was a nursing home, and both acknowledged lack of detailed knowledge about the agency. The facility’s own discharge planning policy required an IDT‑driven, documented discharge plan that identified a discharge destination meeting the resident’s health and safety needs and involved the resident and RP, but interviews with the DON, ADM, BOM, RPs, and emergency contacts showed there was no documented IDT discharge meeting for either resident, inconsistent or absent notification to RPs on the day of discharge, and no documented evaluation or communication of a specific, appropriate post‑discharge provider at the time the residents left the facility.