Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to maintain discharge planning for a resident’s requested move closer to family. The resident had impaired memory and severely impaired decision-making skills, and the guardian repeatedly stated a desire for the resident to move closer to family. The care plan listed the goal, but records lacked referral details, follow-up, or documented communication about the request, and a later care conference documented no discharge planning because the resident was on LTC hospice.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
A resident who had undergone cervical spine surgery and needed ongoing skilled care was being planned for discharge home, but the discharge was later canceled due to medical reasons and he was transferred to a GACH after a change in condition. After hospitalization, the facility declined readmission, citing an expired bed hold and no available bed, even though later census records showed male beds became available and the DON confirmed the resident, family, and receiving SNF were not notified. The resident wanted to return, the family wanted him back, and the record did not show a completed discharge plan before hospitalization; DHCS OAH granted the appeal and found the facility had not met legal requirements for involuntary discharge.
Discharge planning failed for multiple residents when the IDT did not develop resident-specific plans, update goals as needs changed, or ensure needed post-discharge services and equipment were arranged before discharge. A resident with impaired cognition was discharged home without wound care, PT, OT, and HHA services in place and was later found on the floor with serious medical complications. Other residents had generalized care plans that did not reflect their wishes or documented needs such as skilled nursing, therapy, DME, and home health support.
A facility failed to document the reason for resident transfers when it temporarily closed and moved 16 residents to a sister facility. Records for three residents showed no transfer reason in the chart, even though one resident’s daughter/POA and two legal guardians were contacted and agreed to the move. One guardian said the first notice received was an email about renovations and relocation, and the Administrator confirmed phone calls were made but not documented.
Failure to readmit a resident after hospitalization: A resident with autism, ADHD, OCD, anxiety, seizures, gastroparesis, and POTS became distressed after being told she would have a roommate and called 911 stating she did not feel safe and had suicidal thoughts. She was sent to the hospital, where records later showed she was medically stable and a safe discharge plan back to the facility was coordinated, but facility leadership refused readmission because of the SI she had expressed. The medical record also lacked documentation of why her needs could no longer be met or the basis for discharge.
Failure to Maintain Discharge Planning for Resident’s Requested Move Closer to Family
Penalty
Summary
The facility failed to maintain an adequate discharge planning process for a resident whose legal guardian repeatedly expressed a desire for the resident to move closer to family. The resident’s quarterly MDS, dated 5/13/26, identified short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and Section Q indicated there was no active discharge planning occurring for return to the community. The resident’s care plan, printed 6/2/26, documented a discharge goal to move to a facility closer to family, with social services to coordinate discharge services, but the care plan did not include information about referrals sent, updates, or outcomes of referrals. The resident’s progress notes from 12/1/25 through 6/2/26 did not document referrals, follow-up, or communication with the guardian about the request to move closer to family. A social service care conference on 12/31/25 documented that family wanted the resident moved to a facility closer to them in Shoreview, MN, and noted the resident had been denied at many SNFs. A later care conference on 5/29/26 documented no discharge planning needed because the resident was LTC hospice. During interviews, RN staff and the RN manager stated social services led discharge planning, while social services stated the resident’s guardian still wanted the resident moved closer to family and that discharge had not been discussed during the most recent care conference.
Failure to Issue Emergency Discharge Notice
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice for Resident #1 when the resident was discharged to the hospital and then not allowed to return to the facility. The resident’s face sheet showed admission to the facility and discharge to the local hospital on 5/20/26, and the progress notes documented that the resident was discharged back to the hospital at 11:48 A.M. for uncontrolled pain. Review of the resident’s medical record did not contain documentation of an emergency discharge notice issued to the resident. During interviews, the DON stated the facility was not informed of the full acuity of care and believed it could not meet the resident’s needs, and the Administrator stated the resident’s acuity was much higher than anticipated, the resident was sent to the hospital, and the hospital social worker was told the resident would not be permitted back because of the level of care needed; the Administrator also stated no written discharge was issued.
Failure to Complete Discharge Process and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process for one resident who had been admitted after cervical spine surgery and required ongoing skilled nursing, rehabilitation, respiratory, medication management, catheter, and wound care services. Social services notes showed the facility was actively planning for discharge home, with home health services, durable medical equipment, caregiver support, and community services being arranged, but the planned discharge was later canceled by the physician due to medical reasons. The resident then experienced a significant change in condition and was transferred to a GACH. After the hospitalization, the GACH case manager contacted the facility about readmission, but the facility declined to accept the resident back on several occasions. The resident and a family member repeatedly requested contact with the facility because they wanted him to return there. The resident stated he wanted to return because he liked the facility, believed it could meet his needs, and was familiar with the staff and services. The family member stated the facility was chosen because it was closest to home and that she wanted him to return. The Administrator and DON stated the resident was not denied readmission because of behavior, care needs, equipment needs, or inability to provide care, but because the seven-day bed hold had expired and there were no available beds when the hospital requested readmission. However, census records showed available male beds existed after the transfer, and the DON confirmed the facility did not notify the resident, his family member, or the other SNF when beds later became available. The resident’s record also did not show a completed discharge plan before hospitalization or documentation that the discharge process had been completed. A DHCS Office of Administrative Hearings and Appeals document stated the appeal was granted and that the facility had not met the legal requirements to involuntarily discharge the resident.
Discharge Planning Failed to Ensure Resident-Specific Needs Were in Place
Penalty
Summary
The facility failed to implement an effective discharge planning process for multiple residents whose records were reviewed. For Resident #4, a discharge care plan was started after the resident chose to return to the community, but it was not developed by the interdisciplinary team, did not include the resident’s goals or treatment preferences, and did not identify the discharge location or post-discharge needs such as equipment or home health services. The plan was not regularly re-evaluated or updated as the resident’s situation changed, even though the resident later appealed insurance coverage decisions, considered long-term care Medicaid, and ultimately discharged home. Resident #4’s record also showed that a nurse practitioner documented the need for skilled nursing wound care, PT, OT, and a home health aide before discharge, but those services were not in place when the resident left the facility. Social services notes documenting discharge decisions and a referral for home health were entered late and were not added to the discharge care plan. After discharge, the resident was found on the floor in the apartment with vomit and urine, was hypotensive and hypothermic, and was diagnosed with traumatic rhabdomyolysis, acute kidney injury, and cellulitis in both lower legs. The ED record stated the resident reported wound care had not been provided since discharge. Similar discharge planning failures were identified for Residents #8, #9, and #10. Resident #8’s discharge care plan contained generalized interventions and was not updated to reflect the resident’s stated wish to go home or the specific equipment and services documented as needed, including skilled nursing, PT, speech therapy, OT, and a home health aide. Resident #9’s care plan also used generalized goals, did not reflect the resident’s discharge preferences, and did not address the need for skilled nursing, PT, OT, home health aide services, or the resident’s transfer difficulty noted during an IDT meeting. Resident #10’s discharge care plan likewise lacked resident-specific interventions and did not address the equipment and services needed after the resident’s bilateral lower-extremity amputations; the discharge summary omitted needed equipment and post-discharge services, and the resident was discharged without the hospital bed and other supports documented as needed.
Failure to Document Transfer Reasons and Prepare Residents for Facility Closure
Penalty
Summary
The facility failed to document the reason for a facility-initiated transfer in the medical record when it temporarily ceased operations and transferred residents to another facility. This affected all 16 residents who were moved out of the building. Review of the records for three residents showed no documentation in their progress notes explaining why the transfers occurred, even though discharge paperwork identified transfer to a sister facility. Resident #17 had diagnoses including major depressive disorder, dementia, and generalized anxiety disorder, and an MDS assessment showed moderately impaired cognition. The record showed the Executive Director spoke with the resident’s daughter/POA on the day of transfer, and the daughter agreed to the move, but the chart did not document the reason for the transfer. The daughter stated she received the discharge notice the same day the resident was moved. Resident #18 had diagnoses including senile degeneration of the brain, anxiety disorder, cognitive communication deficit, and dysthymic disorder, with severely impaired cognition and a legal guardian. The record showed the Executive Director spoke with the guardian on the day of transfer, and the guardian agreed to the move, but the reason for transfer was not documented. Resident #15 had diagnoses including psychosis, generalized anxiety disorder, dementia, and schizoaffective disorder, with moderately impaired cognition and a legal guardian. The record showed the Executive Director left a voicemail for the guardian about referrals for transfer, and the guardian later stated the first notice he received was an email saying residents would need to be relocated because of renovations. The Administrator and SSD confirmed the decision to close the building for renovations and that phone calls were made, but there was no documentation of those calls or of the transfer reason in the resident records.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization and failed to document the reason for discharge in the medical record. The resident involved had diagnoses including autism spectrum disorder, ADHD, OCD, generalized anxiety disorder, gastroparesis, seizures, and POTS. The record also showed intact cognition and no behaviors on the MDS assessment reviewed by surveyors. The resident became upset after being told she would have a roommate following a room change from a private room to a non-private room on the second floor. Facility notes documented that she repeatedly stated she did not want a roommate, said she would go to the hospital if she had to have one, attempted to remove the roommate’s belongings, and then called 911 stating she did not feel safe. She was sent to the hospital after expressing suicidal thoughts related to the roommate situation. Hospital records showed the resident remained inpatient for an extended period after being medically stable for discharge while placement was coordinated. The hospital documented that she did not want to return to the same facility and that if she were sent back she would kill herself. Later hospital notes documented that no inpatient psychiatric facility could accept her, that a safe discharge plan back to the nursing home had to be coordinated, and that the resident later stated she would return with support and would ask for help or call 911 if suicidal thoughts recurred. Facility leadership reported the final decision not to accept her back was made because of the suicidal ideations she expressed related to the facility, but the record contained no documentation explaining why her needs could no longer be met at the facility or the basis for the discharge.
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