F0627

D

Failure to Properly Justify and Document Involuntary Discharges

Chicago, Illinois Survey Completed on 02-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that involuntary transfers and discharges were not based solely on residents’ conditions at the time of transfer to acute care and to obtain and maintain required physician documentation supporting the reasons for involuntary discharge. For one resident (R1), who had a diagnosis of depression and no documented history of physical, verbal, or other behavioral symptoms on the most recent MDS, the facility initiated an involuntary transfer and discharge after the resident expressed depression over a sister’s recent death, stated a desire to go to the hospital, and cut her own wrist with scissors. Progress notes show the resident was sent to the hospital via 911, returned the same day with stitches, and was placed on 1:1 observation before being petitioned for involuntary discharge to another hospital for psychiatric evaluation and not allowed to return. The administrator and DON both stated that the resident was not a danger to other residents and that the self-harm incident was more like a cry for help, yet the facility issued a Notice of Involuntary Transfer or Discharge citing endangerment to the safety of individuals in the facility.

The notice for R1, addressed to the resident and the legal guardian and signed by the former social services director, documented the regulatory reason as endangerment to the safety of individuals in the facility under 483.15(c)(1)(i)(C). However, the electronic health record contained no physician documentation explaining how the resident endangered the safety of individuals in the facility or supporting the stated regulatory basis for the involuntary discharge. The record also lacked documentation of behaviors that endangered other residents, and the DON and administrator both acknowledged that the resident was not aggressive and did not pose a threat to others. The legal guardian reported being informed by the facility that the resident could not return because she needed 24-hour care and might again use scissors to harm herself, and also reported being satisfied with the resident’s care and wishing the resident could have returned.

For another resident (R4), who had paranoid schizophrenia and a history of smoking in non-designated areas, profanity, and aggressive behaviors toward staff and peers, the facility initiated an involuntary transfer and discharge after staff observed the resident smoking in a non-designated area, becoming verbally aggressive, and refusing redirection. Progress notes described the resident as a threat and harmful to self and others and noted that nursing staff contacted the physician, who recommended further evaluation, after which the resident was petitioned and sent to the hospital. The social services director completed and signed a Notice of Involuntary Transfer or Discharge citing that the resident’s welfare and needs could not be met by the facility under 483.15(c)(1)(i)(A), stating that the facility could not accommodate the resident’s smoking schedule and supervision needs and that the resident had violated the smoking policy multiple times. However, the electronic health record lacked physician documentation of the reason for the proposed discharge, did not specify what services the facility was unable to provide to meet the resident’s needs, and did not document what the facility attempted beyond a smoking behavior contract, resulting in a failure to support the regulatory basis for the involuntary discharge in the clinical record.