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:
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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