F0627

J

Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC

Torrance, California Survey Completed on 02-06-2026

Penalty

Fine: $24,845

Summary

The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning for a resident who was a Regional Center client with schizoaffective disorder bipolar type, unspecified psychosis, anxiety disorder, seizures, anemia, and severe cognitive impairment. The resident’s face sheet identified a conservator as the responsible party, and the MDS dated 11/19/2025 documented severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs, with no ability to ambulate independently. The resident had documented high elopement risk and fall risk, including balance problems and decreased muscular coordination. Social Services documentation from 11/10/2025 indicated the resident came from a homeless environment and might need additional help once discharged home with the support of the conservator. An IDT conference on 11/14/2025 included the conservator by phone, but no discharge planning was discussed at that time, and the notes indicated the bed hold policy and discharge plan would be reviewed with the responsible party/conservator.

On 1/28/2026, a physician’s order was obtained to discharge the resident to a recuperative care center (RCC). A progress note timed at 1:20 p.m. on that date documented that the resident was discharged and picked up by EMT personnel, with standard safety checks such as identity verification, confirmation of transfer destination, attachment of transfer documents, and securing the resident on a gurney. The same note indicated that a voicemail was sent to the conservator notifying them of the transfer, but there was no documentation of prior discussion, involvement, or consent from the conservator regarding the discharge plan or the choice of RCC. Social Services Staff stated that the resident was conserved under a Public Guardian and that the facility did not discuss the discharge planning or transfer to the RCC with the conservator, and that no IDT meeting was held related to the discharge plan prior to discharge. The DON stated that she and Social Services decided to transfer the resident to the RCC because the resident did not meet skilled criteria and needed a lower level of care where medications would be managed, and acknowledged that the conservator was not involved in the discharge planning or discharge and that there was no IDT meeting conducted for this discharge.

The facility also failed to ensure adequate communication and clinical handoff to the receiving RCC. LVN 1 described the expected discharge process as including obtaining a physician’s order, performing a skin assessment, notifying the family or conservator, preparing discharge paperwork, printing the face sheet and medication summary, and contacting the receiving facility. LVN 1 stated these steps were not fully completed for this resident’s discharge, that he was unable to communicate with the conservator or the receiving facility, did not communicate with a receiving nurse, did not perform medication reconciliation, and did not endorse the resident’s medical history to the receiving facility. He reported that paperwork was handed to EMT personnel at the time of discharge and that he failed to verify the type of setting at the RCC to ensure it could meet the resident’s needs. Subsequently, EMS and hospital records documented that the resident was found wandering in the street in the early morning hours, not alert or oriented, with insect eggs on her clothes and hands, and was transported to a general acute care hospital where she was admitted with acute psychosis and altered mental status. Interviews with the conservator, CNA staff, and review of the facility’s discharge planning policy further confirmed that the resident’s discharge occurred without the required involvement of the conservator, without an IDT discharge planning process, and without appropriate clinical communication to the receiving RCC.

The facility’s own policy on discharge planning required the Social Services Director or designee to be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return home, working with the IDT, physician, resident, and resident’s representative. The policy specified that discharge planning services and any changes to the discharge plan were to be discussed with the resident and, if indicated, the resident’s representative, and documented in the medical record. In this case, interviews and record review showed that the conservator was not involved in selecting the RCC or consenting to the discharge, that no IDT meeting was held to assess the resident’s cognitive, medical, physical, and psychosocial needs prior to discharge to a lower level of care, and that the RCC was not properly notified of the resident’s diagnoses, medications, history of wandering, and risk for falls and seizures prior to transfer. These actions and omissions constituted the deficient practice cited under F-627 for failure to ensure a safe and appropriate discharge for this resident.

Removal Plan

• The DON/designee conducted an immediate clinical review of Resident 1’s status in collaboration with the GACH, including medication reconciliation and continuity of care.
• The IDT (Social Service, DOR, DON, ADON/QA Nurse, DSD, MDS Nurse) met to review root cause analysis and ensure discharge planning criteria/process compliance.
• The IDT (SSD, DON, ADON) conducted a facility-wide review of discharges, focusing on level of care determination, IDT involvement, legal representative notification/consent, safe discharge destination, and medication reconciliation/continuity.
• Require licensed nursing staff to notify the SSD of all resident discharges and have discharge information communicated to the SSD and reviewed during the weekly discharge planning meeting (including assessment of cognitive impairment, elopement risk, behavioral symptoms, conservatorship/legal representative involvement, and discharge planning), with variances corrected immediately.
• Require DON or designee to provide final authorization prior to discharge.
• During weekends/when SSD and DON are not physically present, require the Nursing Supervisor to review discharge documentation, confirm completion of required steps, and notify the SSD and DON for follow-up review.
• Implement a Hard Stop Discharge Protocol using a standardized interdisciplinary discharge checklist; no resident may be discharged until all checklist steps are completed.
• Require final approval by the Administrator or DON for all planned discharges to lower levels of care (including RCFE, ALF, ILF, and recuperative care) upon completion of the Hard Stop checklist.
• Require discharge planning to begin at baseline admission and be reviewed at least 30 days prior to projected discharge, again 7 days prior, and prior to the day of discharge.
• Assign QA Nurse responsibility for resident assessment and participation in the discharge process.
• Assign IDT (SSD, DOR, DON, DSS, QA) responsibility for reviewing discharge planning.
• Assign DON/QA/DON designee responsibility for reviewing clinical readiness and safety prior to discharge.
• Require licensed nursing staff to provide a complete handoff to the receiving provider/facility at discharge (clinical status, medications, care needs, follow-up requirements) and document the handoff in the medical record.
• Require SSD and licensed nursing staff to notify the resident’s guardian/responsible party regarding discharge planning, provide discharge destination options, and document preferences/consent in the medical record.
• Assign SSD responsibility for all discharge notices and documentation (notify resident/guardian/responsible party, document discharge plan and chosen destination, maintain related forms/communications in the medical record, ensure timely completion).
• Require Nursing Supervisor or licensed nursing staff to provide a complete handoff report to the receiving facility at discharge (clinical status, medications, care needs, behavioral considerations, follow-up requirements) and document it in the medical record.
• Require SSD to complete post-discharge follow-up/wellness check within 72 hours to confirm safe arrival, medication/care management, identify concerns, and document follow-up actions.
• Provide in-service training to the DON and Administrator on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring.
• Provide 1:1 in-service and competency validation with the SSD on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations.
• Educate all licensed nurses, Social Services staff, and IDT members on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria; provide training by DON and SSD with attendance logs; include in new hire orientation.
• Audit all resident discharges using the Hard Stop Discharge Checklist (daily for first 2 weeks, weekly for next 4 weeks, then monthly) through QAPI to ensure ongoing compliance.
• Ensure on the day of discharge the licensed nurse provides a complete report/handoff to the receiving facility prior to transfer.
• Have Medical Records review audit findings and report results to DON/ADON/QA team; correct discrepancies timely; report results to the QAPI Committee by DON and SSD.
• Incorporate the discharge process into the facility’s QAPI program, including tracking/trending discharge variances, identifying root causes, implementing corrective actions, and reporting findings to leadership, with a performance goal of 100% compliance.