F0627

E

Failure to Justify Discharge and Ensure Safe, Coordinated Transfer for Psychiatric Resident

Fort Worth, Texas Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident was not transferred or discharged unless the transfer or discharge was necessary for the resident’s welfare, that the resident’s needs could not be met in the facility, or that the safety or health of others was endangered, and the failure to implement an effective discharge planning process. The resident was an adult male with Parkinsonism, seizure disorder, anxiety, depression, and schizophrenia, with a BIMS score of 03 indicating severe cognitive impairment and fluctuating delirium. His MDS and care plan documented mood issues, isolation, and a history of behaviors, including two prior aggressive incidents toward other residents, but also reflected that he had no documented ongoing physical or verbal aggression at the time of the 12/01/25 assessment. He was on multiple psychotropic medications and received psychological and psychiatric services, with a psychological note on 12/11/25 indicating no current risk factors for self-injury, sexual acting out, homicidal, or aggressive behavior, and describing him as engaged and interactive in therapy.

Despite this, on 12/12/25 the facility issued a 30‑day discharge notice citing that the safety and health of other individuals were endangered and that the resident’s needs could not be met. The clinical record did not contain clear documentation that his needs could not be met in the facility or that he posed a danger that could not be managed through care planning or IDT interventions. Nursing notes from December 2025 through early February 2026 documented periodic behavioral concerns such as medication refusals, yelling, wandering into other residents’ rooms, verbal altercations, and two physical incidents: a shoulder bump of the maintenance director on 12/26/25 and pushing another resident on 01/12/26. The facility placed him on 1:1 monitoring after these events and notified the PMHNP, who adjusted his antipsychotic medication, but the nursing documentation did not reflect evaluation of the effectiveness of the increased antipsychotic dose or that identified behavioral interventions had been exhausted or found ineffective. The facility also did not report the 01/12/26 resident‑to‑resident physical aggression to the state incident system (TULIP).

The facility then obtained an Order of Protective Custody and sent the resident to an inpatient behavioral hospital for psychiatric evaluation and stabilization, with the ADM stating the OPC was obtained because they “needed him out as soon as possible” and believed he was on the verge of harming someone. The resident’s RP reported not being informed of the transfer beforehand, not consenting to the transfer or discharge, and not being aware of any group home plan, while the SW and ADM described efforts to find alternate placement and a group home, and stated that the final decision not to accept the resident back after psychiatric hospitalization was made by the ADM. The behavioral hospital’s Director of Clinical Services reported that the facility had issued a 30‑day discharge notice, that the resident had been stabilized with no violent incidents for several days prior to an attempted discharge, and that the nursing facility communicated it would not accept the resident back, despite the resident still being legally their resident and without providing clear discharge planning assistance. Conflicting accounts and poor coordination among the facility, the behavioral hospital, the group home agency, and the RP resulted in the resident being discharged from the behavioral hospital without confirmed placement and being returned when a purported group home was found to be vacant. The surveyors found that the facility failed to ensure a safe and orderly transfer and discharge process and refused to readmit the resident after inpatient psychiatric stabilization, without adequate documentation that his needs could not be met or that he posed an unmanageable danger, and without an effective discharge planning process focused on his discharge goals and continuity of care.