F0627

D

Failure to Properly Justify, Plan, and Document Resident Discharges and Non‑Readmissions

Logan, Utah Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that transfers and discharges were only carried out under permissible conditions, were properly planned and coordinated, and were supported by complete and accurate documentation. For one resident with liver cell carcinoma, heart failure, and a terminal prognosis who had been admitted for comfort management and hospice, the care plan and social services documentation identified a discharge plan of continued LTC with skilled nursing and hospice. Subsequent provider and hospice notes documented clinical decline, including dizziness, severe abdominal pain, weakness, nausea, vomiting, jaundice, and markedly reduced oral intake, without any indication of an upcoming discharge. Despite this, the resident was discharged on the same day a hospice nurse documented further decline, and the first mention of discharge in the record appeared in a hospice chaplain note stating the resident was being asked to leave and did not know where he was going.

The facility’s discharge documentation for this resident was incomplete and inaccurate. A Transition of Care/Discharge Summary was printed on the day of discharge using an incorrect discharge date from a prior year and listing the discharge destination as the resident’s RV with home health services, with a goal that he would continue to get stronger with home health. The document omitted any reference to hospice services. All signatures were dated later that afternoon, after the hospice chaplain note, and a nursing progress note recorded that discharge teaching was done and the resident left in a private vehicle with a three‑day supply of medications. Hospice records later showed the resident was actually on LOA and staying at his ex‑wife’s home, and the Social Services Director stated she did not complete the discharge summary, was not involved in the discharge process, and that this lack of involvement was not normal. The Regional Social Work Director determined that staff had reused a prior discharge summary from a previous discharge to the RV, and the hospice director confirmed there was no prior hospice documentation of a planned facility discharge.

For a second resident with diffuse TBI, spastic hemiplegia, major depressive disorder, paraplegia, antisocial personality disorder, and suicidal ideations, the facility discharged the resident following episodes of severe aggression and self‑harm behaviors without required physician documentation supporting the discharge and non‑readmission. A nursing progress note described escalating verbal aggression, vulgar language, physical aggression toward staff, attempts to tip the wheelchair, and throwing objects at staff. A discharge summary later characterized the resident as having physical and verbal aggression that staff were unable to manage and a history of suicidal ideation, but there was no physician documentation explaining why the facility was unable to care for the resident, what interventions had been attempted, or why the resident was not readmitted after hospital transfer. Interviews with the Restorative Therapy Aide, ADON, SSD, and Administrator described multiple aggressive incidents, blue‑sheeting to the hospital, suicide attempts, and the facility’s decision not to readmit the resident due to safety concerns, but these details were not supported by corresponding physician documentation in the medical record. Additionally, for the first resident, there was no care plan addressing aggressive behaviors despite multiple progress notes documenting such behaviors, and no documentation of hospice being contacted about behavioral concerns, medication adjustments, or room changes prior to discharge.