F0627

J

Unsafe Discharges to Independent Living Without Adequate Planning or Support

Richmond, Virginia Survey Completed on 02-06-2026

Penalty

Fine: $16,820

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.