Failure to Document and Coordinate Safe Discharge Planning and Home Health Referrals
Summary
The deficiency involves the facility’s failure to ensure that discharge planning for one cognitively intact resident included documented coordination of services, resident participation, and verification of a safe and appropriate transition to the community. The facility’s own Discharge Planning policy requires timely documentation of discharge needs and plans, discussion of the evaluation results with the resident or representative, and development of a post-discharge plan of care indicating the discharge location and arrangements for follow-up care and services. For this resident, the medical record did not contain a completed discharge summary, documentation of a care conference discharge meeting, or confirmation that post-discharge needs and services were fully addressed prior to discharge. The only progress note related to discharge indicated that the resident was discharged home with paperwork and medications, that van transport arrived, and that a family member was waiting at the destination. The resident was admitted with respiratory failure, cognitive communication deficit, heart failure, and muscle weakness, and had significant functional limitations requiring substantial/maximal assistance with transfers and dependence for walking at admission. At discharge, the MDS showed the resident remained cognitively intact with a BIMS score of 13, required partial/moderate assistance for sit-to-stand and bed-to-chair transfers, and was not assessed for car transfer or walking 10 feet due to medical or safety concerns. The care plan documented that the resident wished to discharge home or to the community, with interventions to evaluate the resident’s motivation and ability to safely return to the community and to identify gaps in abilities affecting discharge. However, there was no documentation that these evaluations and care plan interventions were completed or that discharge goals were met before the resident left the facility. Interviews with staff revealed that the social worker managed discharge planning and home health referrals but did not document care conferences or discharge planning discussions in the medical record, instead keeping and then deleting personal notes. The LPN reported that nursing’s role in discharge was limited to belongings and medication management, that a paper discharge checklist was used but not part of the medical record, and that the discharge was “fast and abrupt” once insurance ended. The OT stated that therapy determined the resident was not appropriate to live alone at discharge, recommended home health services, and communicated these recommendations to the social worker, but the medical record contained no documentation that home health referrals were initiated, completed, or formally declined by the resident. The social worker reported that a phone conversation with the resident’s brother led to not sending the home health referral, based on the brother’s reluctance to have services in the home and his statement that family would assist, but this was not documented, and the facility did not verify this information with the resident, who was his own decision maker. There was no documentation confirming the adequacy of caregiver support or the safety of the discharge environment, and leadership acknowledged that the expected discharge summary, care conference documentation, and follow-through on therapy referrals were not present in the record.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing Discharge Care Plan: A resident with OCPD and intact cognition did not have a discharge care plan despite care plan meetings discussing short-term stay, psychiatric services, and later transfer to a long-term psych facility. The comprehensive care plan had no discharge plan, and staff interviews showed confusion between the SW and MDS Coordinator about who was responsible for developing it.
A resident with stroke-related deficits, AFib, CVA, and hemiparesis was sent to the ED for possible infection and later found stable to return, but facility leadership refused readmission. Hospital staff and the resident reported the resident wanted to come back, while the Administrator, DON, and Corporate Nurse gave conflicting explanations tied to a bed hold form, alleged behavior issues, and money owed. The resident also reported being yelled at and pressured during hospital meetings about returning.
A resident with a recent hip fracture, bipolar disorder, and anxiety disorder was allowed out on therapeutic pass but was not permitted to return when she came back after the pass. Staff completed discharge paperwork, packed her belongings, and treated her as discharged even though the facility’s policy stated residents must be allowed to return after therapeutic leave regardless of payment source. The resident said she had nowhere to go, and the record showed conflicting staff accounts about whether she had left AMA or could return.
A resident with a G-tube, Foley catheter, oxygen needs, malnutrition, and a stage 2 sacral pressure ulcer was discharged without a safe, orderly plan in place. The record showed missing discharge documentation, no confirmed home health or DME arrangements, and no documented tube-feeding, wound-care, or Foley-supply education. The resident reported receiving only a few bottles of tube feeding, having no pump or supplies, going days without oxygen, and having no wound-care supplies or home health aide support after discharge.
A resident with dementia, anxiety, depression, and a BKA was sent to the hospital after yelling at staff and calling 911, but the facility used an AMA form for the transfer even though staff later said AMA paperwork was not meant for hospital transfers. The resident had a court-appointed guardian, the AMA and bed hold paperwork were incomplete, and the facility then refused to take the resident back, leaving the guardian to find another placement.
Failure to Explain Medicaid Share of Cost Before Eviction Notice: A resident with intact cognition and diagnoses including epilepsy, insomnia, and gait/mobility abnormalities was told about unpaid Medicaid share of cost and a pending discharge, but the charge was not fully explained by business office staff and/or the SSD. The SSD could not provide documentation that the share of cost was explained before the initial eviction notice was issued, despite the resident stating the amount was not clearly understood.
Missing Discharge Care Plan
Penalty
Summary
The facility failed to develop a discharge care plan for Resident #83, who was admitted with obsessive-compulsive personality disorder (OCPD). A care plan meeting on 12/01/25 documented that the resident did not wish to attend and that the interdisciplinary team, including the Business Office Manager, Social Worker, DON, and Administrator, discussed that she would remain at the facility short-term, receive psychiatric services before discharging home, and had no barriers to discharge. The admission MDS assessment noted the resident had intact cognition, her overall goal was to discharge to the community, there was no active discharge planning in place, and she did not want to be asked about returning to the community on all MDS assessments. A later care plan meeting on 01/21/26 documented that the resident again did not attend and that her recent inpatient psychiatric admission was discussed, with Family Member #1 stating they now wanted her transferred to a long-term psychiatric facility for treatment. Review of the comprehensive care plan, last revised on 03/03/26, showed no discharge care plan. The discharge-return not anticipated MDS indicated the resident discharged to an inpatient psychiatric facility. During interviews, the SW stated discharge planning begins on admission and that the MDS Coordinator was typically responsible for the discharge care plan, while the MDS Coordinator said there was confusion about whether the MDS Coordinator or SW was responsible and confirmed the resident did not have a discharge care plan. The Administrator stated a discharge care plan should be part of the comprehensive care plan and that the SW was responsible for starting discharge planning on admission and documenting updates as needs or goals changed.
Unsafe discharge and refusal to readmit after hospital transfer
Penalty
Summary
The facility failed to provide a safe and planned discharge to an appropriate facility for one resident who had diagnoses including frontal lobe and executive function deficit stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis. The resident’s MDS also documented the resident as cognitively intact. The resident was transferred to the emergency department for further evaluation and treatment after staff noted possible infection, and the resident stated the transfer was agreed to because the resident was not feeling well and staff said the resident did not look well. After the resident was treated in the emergency department and found stable to return to the facility, multiple hospital staff reported that the facility refused to accept the resident back. The resident stated the resident wanted to return and had not told the facility otherwise until after being told the facility did not want the resident back. The resident also stated facility leadership came to the hospital, was verbally abusive, yelled at the resident, and told the resident the resident could not return because of behavioral issues and money owed to the facility. Hospital staff similarly stated the facility said the resident was not welcomed back and that the resident knew why, and they described the facility representatives as rude, unpleasant, and harassing during discussions about the resident’s return. Facility staff gave conflicting accounts about the resident’s return. The DON stated the resident was sent out for weakness, dizziness, and pallor, and later said the resident refused to sign a bed hold agreement. The Administrator stated the resident had to make changes and pay toward the bill before returning, and the Corporate Nurse later stated the resident was appropriately discharged because the resident said the resident was not going to return. The record also showed the resident’s care plan included the resident’s wish to discharge to another facility or the community at a future date of the resident’s choosing, with referrals to be made to facilities of the resident’s choice. The facility bed hold policy stated private pay residents who do not sign the bed hold/transfer letter, do not pay the bed hold per diem, or communicate they will not be returning will be discharged after written notice.
Failure to Allow Return After Therapeutic Leave and Inadequate Discharge Planning
Penalty
Summary
The facility failed to permit a resident to return after therapeutic leave and failed to develop and implement an effective discharge planning process focused on the resident’s discharge goals. Resident #11 was admitted with diagnoses including a right femur fracture, bipolar disorder, and anxiety disorder. Her baseline care plan listed a goal to discharge to the community with assistance as needed, and her admission assessment showed she was cognitively intact with a BIMS score of 15, had mild depressive symptoms, used a walker and wheelchair, and required partial/moderate assistance with several activities of daily living. The resident had physician orders allowing therapeutic pass with medications, and her admission agreement stated that residents may leave for therapeutic home visits with permission and shall be signed out and back in, with a bedhold policy in place. She also had a nursing home transfer and discharge notice dated 6/12/26 stating she would be discharged for nonpayment effective 7/30/26. Her medical record also showed a recent hospital visit after posterior hip replacement surgery, with instructions to avoid bending the hip more than 90 degrees for the first 6 weeks and a right hip incision noted on the after-visit summary. On 6/30/26, the resident left on pass with a documented plan to return later that day. When she had not returned by early the next morning, staff notified her responsible party and the DON, and a transfer/discharge report was completed showing a discharge date of 6/30/26. Later that day, the resident returned to the facility and stated she had been told she was discharged, that her belongings were packed, and that she had nowhere to go. Staff interviews showed conflicting accounts about whether she had left against medical advice or was allowed to return, while the facility’s therapeutic leave policy stated that residents must be permitted to return after therapeutic leave regardless of payment source and that not permitting return constitutes a discharge. The record also reflected that the resident had lived in a homeless shelter before admission and that the facility discussed discharge because she was not at the facility at midnight and had an outstanding balance.
Incomplete discharge planning and missing supplies for a medically complex resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with multiple complex medical needs, including dysphagia, COPD/emphysema, depression, anxiety, severe protein malnutrition/cachexia, a stage 2 sacral pressure ulcer, urinary retention with a Foley catheter, and a G-tube for enteral feeding. The resident was discharged home/community with services, but the record and interviews showed that discharge planning was incomplete and that key discharge needs were not in place at the time of discharge. The resident reported that when she left the facility she received only four bottles of tube feeding and no education, pump, or other tube-feeding supplies, and that she and her son had to administer the feeding manually. She also reported going 13 days without oxygen and having to contact the oxygen company herself to obtain it at home. She stated that she received no supplies for her pressure ulcer, no home health aide support, and no medical equipment when she returned home. The resident also reported increased pain from the worsened sacral wound after discharge. The discharge documentation reflected missing or incomplete information, including no transportation arrangement, no documented primary provider or follow-up appointments, no pharmacy information, no agencies contacted for home care, and no indication that tube feeding, Foley catheter care/supplies, or wound care supplies were needed. The discharge summary also indicated regular diet and thin liquids, did not select tube feeding, and listed the resident as continent despite the presence of a Foley catheter. Progress notes showed no discharge note from social work or the medical provider, and staff interviews confirmed that home health, DME, oxygen, tube-feeding education, and discharge documentation were not fully in place when the resident left the facility.
Improper AMA paperwork and refusal to readmit after hospital transfer
Penalty
Summary
The facility issued an AMA form when a resident with dementia, anxiety, depression, and a right BKA was transferred to the hospital, even though multiple staff later stated that AMA paperwork was not typically used for a resident going to the hospital. The resident had a court-appointed guardian, and the chart showed the guardian was aware of the resident’s behavior and hospital transfer. The AMA form in the record was largely incomplete, with only the resident’s name and signature, a note that the guardian was aware of the decision, and an RN signature. The resident’s progress note documented that he was yelling at staff, stating he was calling 911 because he did not feel good and the hospital had not helped him. Staff attempted to assess him, vital signs were taken and described as stable, and the guardian was called to discuss the situation. The note stated the resident signed the AMA form, the guardian was aware of the AMA status, and management was notified. A bed hold authorization form was also completed when the resident transferred to the hospital, but the daily rate was blank and there was no notation that the guardian was notified. After the hospital transfer, the facility did not permit the resident to return, and the guardian reported having to find another placement. The hospital social worker stated the resident was not his own decision maker and that the facility refusing to take him back was against the rules. The previous SW stated the AMA policy should not be used when a resident goes to the hospital, but when they go home AMA. The NHA stated the resident had behaviors and was noncompliant, and the DON stated he thought the decision was not to take the resident back from the hospital.
Failure to Explain Medicaid Share of Cost Before Eviction Notice
Penalty
Summary
The facility failed to notify Resident 1 of the Medicaid share of cost in a timely manner and did not explain the charge in a way the resident could easily understand. Resident 1 was admitted to the facility with diagnoses including epilepsy, insomnia, and abnormalities of gait and mobility, and a later MDS showed a BIMS score of 15, indicating intact cognitive function. During an interview, Resident 1 stated that the Social Services Director had given a pending discharge date and that the facility had informed the resident of money owed for several months of unpaid share of cost, but that the charge was not fully explained by business office staff and/or the SSD. During a concurrent interview and record review, the SSD reviewed Resident 1's facility invoice and stated that the resident had not paid the share of cost since 7/1/25. The SSD said the initial eviction notice was given on 4/6/26 and a second notice on 6/19/26, but was unable to provide documentation that the Medicaid share of cost charges were explained to Resident 1 before the initial eviction notice was issued. The facility policy titled Facility-Initiated Transfer/Discharge Policy stated that the facility shall protect each resident's right to remain in the facility and shall not transfer or discharge any resident except as permitted under federal and California law.
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