F0627

D

Failure to Provide 30‑Day Notice and Safe Discharge Planning for Two Facility‑Initiated Discharges

Dowagiac, Michigan Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required 30‑day written notice of facility‑initiated discharge, failure to inform residents of their right to appeal, and failure to implement appropriate discharge planning and preparation for two residents. For the first resident, an older male with traumatic ischemia of muscle, diabetes mellitus, neuromuscular bladder dysfunction with an indwelling Foley catheter, bowel incontinence, malnutrition risk, and fluctuating ADL abilities, the MDS showed he was cognitively intact. His care plan included management of his Foley catheter, diabetes, incontinence, and a planned discharge with needed equipment and supplies. Despite this, he reported being told by the NHA that he had to leave because he had met all his goals, and he was discharged to a hotel one day after that meeting without being informed of his right to appeal the discharge and without a glucometer for blood sugar monitoring.

Staff interviews indicated that the first resident sometimes needed help with bowel incontinence and catheter management, and that he expressed concern about having no food when leaving, wishing he had oatmeal and milk to take with him. The former social services staff reported that the resident’s home had been deemed unsafe and uninhabitable by APS, that the resident was hesitant to leave because he knew repairs would take months, and that the facility pushed for discharge due to his outstanding balance and failure to pay. The APS caseworker described the home as having severe clutter, tripping hazards, no running water, utility issues, and a kicked‑in front door, and stated the resident confirmed he could not return there until it was cleaned and repaired. The resident’s DPOA reported being told by the NHA that the resident could not afford to stay, was not informed of any option to remain or appeal, and later learned he had been discharged without her knowledge and without a glucometer. An emergency department note documented that the resident reported being moved from a SNF to a motel, felt unable to care for himself, had no way to check his glucose at home until prescribed a glucometer there, and that EMS had been called by home health because he was covered in feces.

For the second resident, an older male with malignant neoplasm of the colon, alcohol dependence with delirium, and intestinal perforation, the MDS showed severe cognitive impairment (BIMS 5), a colostomy, and independence only for wiping the ostomy opening. His care plan identified impaired cognition with a goal of making safe decisions with staff supervision. Social services documentation showed he was notified one day prior that he would discharge home the next day. His DPOA reported telling the NHA there was no safe place for him to go and no one to care for him, and that the NHA focused on not wanting him to build up medical debt. She stated she ultimately picked him up because an unknown staff member told her that if he was not picked up by midnight, he would be escorted outside and the door locked behind him. She reported that he initially did not want to discharge but agreed after repeated staff inquiries about when his ride was coming, that he had never previously cared for his colostomy, had poor short‑term memory and reduced mobility, and that his walker did not fit through his bathroom door and he had fallen several times at home.

Therapy and nursing leadership interviews confirmed that the second resident should have received colostomy care training and that no documentation of such training existed. The COTA stated that a home evaluation to determine safe use of the walker in the home was not completed and that, due to his cognition, he would have needed repetitive training and displayed impulsivity with unfamiliar tasks. The DON reported the facility could not provide documentation of colostomy training for this resident or catheter and blood glucose training and provision of a glucometer for the first resident. The NHA acknowledged that the DPOA for the second resident did not want him discharged on the identified date but ultimately took him home, asserted that all discharges were voluntary, and confirmed that the facility did not provide either resident with written notice of discharge or information on the right to appeal. The governing body confirmed that the required state involuntary transfer/discharge and appeal forms were not submitted for either resident, and the facility’s own policy required written notice in a language the resident or representative could understand, given at least 30 days before a proposed facility‑initiated discharge.