Unsafe Discharges to Independent Living Without Adequate Planning or Support
Summary
The deficiency involves the facility’s failure to ensure safe, appropriate discharge planning and execution for two residents who were discharged from the facility to independent living settings that did not provide the level of care they required. For the first resident, who had resided in the facility for over three years and had multiple diagnoses including muscle wasting, diabetes, congestive heart failure, atrial fibrillation, cerebral infarction, major depressive disorder, and moderately impaired cognition, the facility discharged the resident to an apartment setting that provided no direct supervision, ADL assistance, or medication administration. The clinical record contained no documented basis from a physician or provider for the discharge, no discharge care plan with goals or identified care needs, and no evidence of interdisciplinary team involvement or care plan review related to discharge. The resident’s MDS indicated the resident did not wish to be asked about returning to the community, and the last comprehensive care plan review months earlier documented no plans to discharge. The first resident had a court-appointed legal guardian authorized to make all decisions, including living arrangements, yet there was no documentation of guardian involvement or consent for the discharge. Facility documents repeatedly referred to the destination as a “group home,” but the location was actually an unlicensed independent living apartment where residents were expected to be independent with all ADLs and where only pill reminders and optional meal preparation were offered. The social worker reported relying on information from the housing owner and did not visit or verify the setting or services, did not document guardian contact, and did not send written notice. The NP and nursing staff believed the resident was going to a licensed group home with a provider and medication administration, and the NP stated the resident required assistance with medications, cueing for hygiene, and could not effectively manage money. The discharge summary omitted several chronic-condition medications previously ordered to continue and contained no documented education on self-administration of Trulicity, despite the resident never having self-administered medications in the facility. The second resident, who had diagnoses including NSTEMI, hemiplegia and hemiparesis after cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, ESRD requiring dialysis, heart failure, and significant ADL and mobility deficits, was also discharged to the same owner’s independent living setting. The resident’s care plan and MDS documented dependence or need for assistance with toileting, bathing, transfers, mobility, dressing, grooming, and bowel incontinence, and a UAI and Medicaid authorization form indicated a need for nursing home level of care. The care plan also documented the resident’s wish to remain long-term at the facility. The discharge summary from the NP stated the resident was stable for discharge to a group home with home health PT/OT, but the clinical record contained no documented discharge planning addressing medication administration, medication education or training, dialysis access management, medical equipment needs, or confirmation that home health services were arranged. For the second resident, the social worker documented only that the resident was interested in discharging to a group home and had met with the group home representative, with no discharge date initially in place, and later noted the discharge was postponed. The social worker did not verify the level of care or services at the destination, did not visit the site, and acknowledged not knowing what services were provided, having assumed it was a group home. The owner of the receiving setting confirmed it was independent living, not licensed, with no staff providing care or medication administration, only pill reminders and meal preparation if desired. The NP and nursing staff believed the resident was going to a staffed group home with CNAs and nurses providing 24-hour care and medication administration, and the NP stated the resident could not manage medications or dialysis-related needs independently and required 24-hour care. These actions and omissions resulted in residents dependent on assistance with ADLs, medications, and in one case dialysis, being discharged to unsupervised independent living without verified support systems, documented discharge planning, or appropriate involvement of the interdisciplinary team and, for the first resident, without the legal guardian’s knowledge or consent. The surveyors determined that these failures constituted an immediate jeopardy situation related to the facility’s obligation to ensure safe, appropriate discharge planning and execution for residents transferring to lower levels of care.
Removal Plan
- Pause all discharges to a lower level of care pending interdisciplinary team (IDT) review.
- Social Services, Assistant Administrator, and Assistant Director of Nursing completed a retrospective review of all residents discharged to a lower level of care, including verifying that medication administration (including injectables) needs and ADL needs were met; residents identified at risk were contacted, reassessed, and supports/services were arranged or offered as appropriate.
- Implement a Discharge Planning Protocol requiring ongoing IDT collaboration to establish a discharge plan; a physician order aligned with the actual discharge location; resident/representative participation and consent; assessment of functional status and care needs; confirmation of medication access and ability to administer medications; and confirmed follow-up appointments and services.
- Require that residents needing assistance with ADLs, dialysis, medications, or supervision may not discharge to a lower level of care without documented support systems.
- Educate all IDT members (Administrator, Assistant Administrator, DON, ADON, Unit Managers, Business Office, Social Services, Therapy, Licensed Nurses, CNAs, and Providers) on appropriate discharge planning using the Transfer and Discharge Policy and F627 requirements, including IDT collaboration, physician order alignment with actual discharge location, resident/representative participation and consent, functional/care needs assessment, medication access/administration confirmation, and confirmed follow-up appointments/services.
- Ensure any staff not present for immediate education are educated prior to working their next scheduled shift.
- Issue phone contacts and/or letters to all residents discharged to a lower level of care.
- Implement a documented discharge protocol that includes a mandatory checklist of required items to be completed prior to any discharges to a lower level of care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with quadriplegia, chronic pain, constipation, and anxiety was sent to an ER after reporting chest tightness and other symptoms, choosing transport to a different ER after declining the local ER. While the resident was out, housekeeping was asked to clean the room, but the resident declined multiple times, and the facility then decided not to readmit the resident. The record did not document the specific needs the facility could not meet or the attempts made to meet the resident’s needs before the readmission denial.
Staff incorrectly told resident representatives that transfers to a higher level of care would be treated as AMA discharges and that the residents could not return. One resident with a UTI, IV therapy, refusal of care, and repeated IV removal was sent to the hospital after the family requested transfer, and another resident was transferred for behavioral issues after the family had asked for acute care. In both cases, staff communications to the family and hospital incorrectly labeled the transfers as AMA.
A resident with anoxic brain injury, dementia, delusional disorder, and DM II was discharged without a completed discharge summary documenting medication or treatment instructions. The Administrator could not produce the completed summary, and the guardian reported no meds were sent home; instead, meds were called into a pharmacy in another city hours away.
A resident with CVA sequelae, DM2, epilepsy, wheelchair use, and assistance needs for transfers and ADLs was discharged to a hotel without a fully developed safe discharge plan. The discharge summary lacked details on transfer support, wound care, and transportation arrangements, and the DON confirmed no physician order was obtained and the summary was incomplete. After discharge, the resident fell while transferring from bed to wheelchair and was taken to the hospital.
Failure to provide involuntary discharge appeal notice: A resident with psychosis, schizoaffective disorder, epilepsy, TBI, dementia, and severe cognitive impairment was sent to the ED for psychiatric evaluation after escalating agitation and behavioral disturbances. The facility issued an involuntary transfer/discharge form stating it could not meet the resident’s needs and that the resident was unsafe for others, but there was no resident or RP signature, and the RP later said she was not told she could appeal or that the facility would not take the resident back.
A resident was transferred to the hospital for evaluation after a change in condition and was not re-admitted afterward. An admission staff member said the resident had been on hospice and that hospice would not take the resident back, but could not explain why the resident was no longer considered a facility patient or whether a bed was available. Family members reported the facility never contacted them about re-admission, despite the facility policy stating residents are to be allowed to return after hospitalization regardless of payer source.
Failure to Document Readmission Decision and Resident Needs
Penalty
Summary
The facility failed to document the specific needs it could not meet and the attempts made to meet a resident’s needs when it declined to readmit the resident after an acute care hospitalization. Resident #35 was admitted with diagnoses including quadriplegia, abnormal posture, chronic pain, idiopathic constipation, and anxiety. The resident had previously received a 30-day involuntary discharge notice for failure to pay, possession of marijuana, recording staff without consent, and violation of a behavior agreement, but that notice was later rescinded until an appropriate and safe alternative placement could be secured. On the day the resident reported chest tightness, chills/diaphoresis, headache, and abdominal discomfort, the RN assessed the resident, obtained vital signs, and offered transfer to the local ER. The resident refused that option and chose to go to another ER, and the RN transported the resident there with paperwork. The resident was medically stable for transfer. While the resident was out of the facility, housekeeping was asked to clean the resident’s room, but the resident declined multiple times, which was noted as an infection control concern. An administrative decision was then made not to readmit the resident, and the justification for the notice of decision not to readmit was reviewed by the physician. Staff later confirmed the resident required catheter care and bowel care, had intermittent impulsive and verbally aggressive behaviors, and that the facility was able to meet the resident’s care needs.
Improper AMA Classification of Resident Transfers
Penalty
Summary
The facility failed to ensure that residents were allowed to return after requests to be sent to an acute care facility were honored, and staff incorrectly treated those transfers as Against Medical Advice (AMA) discharges. This deficiency involved two residents. In both cases, staff told the resident representatives that if the resident was sent out for a higher level of care, it would be considered AMA, even though the transfers were initiated by the facility or requested by the family and later carried out by the facility. For one resident, the record showed the resident was receiving IV fluids and antibiotics for refusal of medications, meals, and treatment for a UTI, and repeatedly pulled out the IV. The resident’s son insisted the resident be sent to the hospital so she could be restrained to keep the IV in place. Staff documented that the physician assistant did not want the resident sent out, and the son was told that sending her out would be AMA. The resident was then sent to the hospital due to worsening edema at the IV site, and the hospital later reported pneumonia, difficulty maintaining blood pressure, intermittent BiPAP use for shortness of breath, oxygen by nasal cannula while awake, and use of restraints for safety because the resident was combative. For the second resident, the family requested transfer to an acute care facility for behavioral issues, but was told the resident could be cared for in the facility and that sending the resident out would be an AMA discharge. Within a few hours, the resident was transferred anyway. The resident representative later reported being told by the hospital social worker that the resident was not allowed to return because of leaving AMA, although the resident had not left AMA. The administrator later confirmed the facility liaison told the acute care facility the resident could not return because the resident left AMA, and the corporate nurse stated the residents were not AMAs and that staff were confused.
Incomplete Discharge Medication Instructions
Penalty
Summary
The facility failed to ensure that a resident had access to medications upon discharge and did not complete the discharge summary with medication or treatment instructions. Resident #50 was admitted with diagnoses including anoxic brain injury, dementia, delusional disorder, and type II diabetes mellitus, and the discharge MDS indicated the resident was cognitively impaired. Review of the discharge summary showed only the social service section was completed, with no instructions provided to the resident or the guardian regarding medications and/or treatments. During interview, the Administrator stated the facility could not produce a completed discharge summary with medication or treatment instructions for the resident. The resident’s guardian stated she had been given instructions, but no medications were sent home with the resident and the medications were called into a pharmacy located in another city hours away. The facility policy required discharge information to include a recap of the resident’s stay and reconciliation of pre- and post-discharge medications.
Unsafe discharge planning and incomplete discharge documentation
Penalty
Summary
The facility failed to ensure Resident #86 was discharged appropriately. The resident was admitted with diagnoses including unspecified sequelae of cerebral infarction, type 2 diabetes mellitus with hyperglycemia, and epilepsy. The resident had a BIMS score of 14, used a wheelchair, had one-sided range-of-motion limitations in the upper and lower extremities, and required assistance or supervision with multiple activities including eating, hygiene, dressing, toileting, transfers, and walking short distances. The care plan stated the resident was to discharge into the community once an appropriate setting was found, and social service notes documented that there was still no community discharge recommendation and no safe discharge plan due to lack of family support and the resident’s unwillingness to pursue potential sources of income. The resident was discharged to a hotel with medications and appointment instructions, but the discharge summary did not identify services to assist with wheelchair transfers, did not specify the wound care needed, and did not state whether the resident could independently arrange transportation to appointments. The DON confirmed a physician order was not obtained before discharge and that the discharge summary was not fully completed and lacked the resident’s signature. The Administrator stated the facility arranged and paid for the hotel room and transportation, provided a gift card, and gave the resident a check from his account. The SSD later reported that the resident fell while transferring from the bed to the wheelchair at the hotel and was taken by emergency services to the hospital, where he remained as of the last review.
Failure to Provide Involuntary Discharge Appeal Notice
Penalty
Summary
The facility failed to provide notification of involuntary discharge that included information about the resident’s right to appeal for one resident reviewed for admission, transfer, and discharge. The facility policy stated that transfer/discharge notices must be provided in a language and manner the resident and representative can understand and must include appeal rights and state contact information. The policy also stated the notice must generally be provided at least 30 days before transfer or discharge, with exceptions for certain urgent circumstances. Resident #29 was admitted with diagnoses including psychosis, schizoaffective disorder, anxiety, epilepsy, traumatic brain injury, and dementia. The record showed a significant change MDS with a Brief Interview for Mental Status score of 00, indicating severe cognitive impairment, along with daily behaviors toward self, dependence on staff for ADLs, and use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. On 7/6/2026, the physician ordered the resident sent to the ED for immediate evaluation due to increased agitation and escalating behavioral disturbances that presented an immediate risk of harm to herself and others, and the resident was transferred to the ER for a psychiatric evaluation. The Nursing Home Notice of Involuntary Transfer or Discharge form dated 7/6/2026 listed reasons for discharge or transfer, including that the nursing home could not care for the resident and that the resident made the nursing home unsafe for other people. The form was signed by the Administrator and Medical Director, but there was no signature from the resident or responsible party. The resident’s responsible party later stated she was unaware she could appeal and reported that the facility did not tell her it would not take the resident back. During interview, the Administrator stated the responsible party was contacted, the situation was explained, and the notice was mailed, but the facility was unable to provide a signed copy of the notice showing that appeal information had been provided.
Failure to Re-Admit Resident After Hospital Transfer
Penalty
Summary
The facility failed to re-admit a resident after the resident was sent to a hospital for evaluation due to a change in condition. During record review, staff confirmed that the resident was transferred to the hospital and was not re-admitted to the facility afterward. An admission staff member stated the resident had been under hospice care before the transfer and explained that when the hospital called to arrange re-admission, hospice would not take the resident back. The staff member further stated the resident was a hospice patient and not a patient of the facility, but did not provide an explanation for how the resident was no longer considered a facility resident. During interviews, the admission staff member did not explain whether there were available beds or whether the resident was placed on a wait list. The resident’s record showed three family members/emergency contacts, and all three family members stated the facility never contacted them regarding re-admission. The facility’s Bed-Holds and Returns policy stated that residents are to be permitted to return to the facility following hospitalization or therapeutic leave regardless of payer source, and that residents seeking to return within the bed-hold period are allowed to return to their previous room if available.
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