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:
Failure to maintain discharge planning for a resident’s requested move closer to family. The resident had impaired memory and severely impaired decision-making skills, and the guardian repeatedly stated a desire for the resident to move closer to family. The care plan listed the goal, but records lacked referral details, follow-up, or documented communication about the request, and a later care conference documented no discharge planning because the resident was on LTC hospice.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
A resident who had undergone cervical spine surgery and needed ongoing skilled care was being planned for discharge home, but the discharge was later canceled due to medical reasons and he was transferred to a GACH after a change in condition. After hospitalization, the facility declined readmission, citing an expired bed hold and no available bed, even though later census records showed male beds became available and the DON confirmed the resident, family, and receiving SNF were not notified. The resident wanted to return, the family wanted him back, and the record did not show a completed discharge plan before hospitalization; DHCS OAH granted the appeal and found the facility had not met legal requirements for involuntary discharge.
Discharge planning failed for multiple residents when the IDT did not develop resident-specific plans, update goals as needs changed, or ensure needed post-discharge services and equipment were arranged before discharge. A resident with impaired cognition was discharged home without wound care, PT, OT, and HHA services in place and was later found on the floor with serious medical complications. Other residents had generalized care plans that did not reflect their wishes or documented needs such as skilled nursing, therapy, DME, and home health support.
A facility failed to document the reason for resident transfers when it temporarily closed and moved 16 residents to a sister facility. Records for three residents showed no transfer reason in the chart, even though one resident’s daughter/POA and two legal guardians were contacted and agreed to the move. One guardian said the first notice received was an email about renovations and relocation, and the Administrator confirmed phone calls were made but not documented.
Failure to readmit a resident after hospitalization: A resident with autism, ADHD, OCD, anxiety, seizures, gastroparesis, and POTS became distressed after being told she would have a roommate and called 911 stating she did not feel safe and had suicidal thoughts. She was sent to the hospital, where records later showed she was medically stable and a safe discharge plan back to the facility was coordinated, but facility leadership refused readmission because of the SI she had expressed. The medical record also lacked documentation of why her needs could no longer be met or the basis for discharge.
Failure to Maintain Discharge Planning for Resident’s Requested Move Closer to Family
Penalty
Summary
The facility failed to maintain an adequate discharge planning process for a resident whose legal guardian repeatedly expressed a desire for the resident to move closer to family. The resident’s quarterly MDS, dated 5/13/26, identified short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and Section Q indicated there was no active discharge planning occurring for return to the community. The resident’s care plan, printed 6/2/26, documented a discharge goal to move to a facility closer to family, with social services to coordinate discharge services, but the care plan did not include information about referrals sent, updates, or outcomes of referrals. The resident’s progress notes from 12/1/25 through 6/2/26 did not document referrals, follow-up, or communication with the guardian about the request to move closer to family. A social service care conference on 12/31/25 documented that family wanted the resident moved to a facility closer to them in Shoreview, MN, and noted the resident had been denied at many SNFs. A later care conference on 5/29/26 documented no discharge planning needed because the resident was LTC hospice. During interviews, RN staff and the RN manager stated social services led discharge planning, while social services stated the resident’s guardian still wanted the resident moved closer to family and that discharge had not been discussed during the most recent care conference.
Failure to Issue Emergency Discharge Notice
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice for Resident #1 when the resident was discharged to the hospital and then not allowed to return to the facility. The resident’s face sheet showed admission to the facility and discharge to the local hospital on 5/20/26, and the progress notes documented that the resident was discharged back to the hospital at 11:48 A.M. for uncontrolled pain. Review of the resident’s medical record did not contain documentation of an emergency discharge notice issued to the resident. During interviews, the DON stated the facility was not informed of the full acuity of care and believed it could not meet the resident’s needs, and the Administrator stated the resident’s acuity was much higher than anticipated, the resident was sent to the hospital, and the hospital social worker was told the resident would not be permitted back because of the level of care needed; the Administrator also stated no written discharge was issued.
Failure to Complete Discharge Process and Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process for one resident who had been admitted after cervical spine surgery and required ongoing skilled nursing, rehabilitation, respiratory, medication management, catheter, and wound care services. Social services notes showed the facility was actively planning for discharge home, with home health services, durable medical equipment, caregiver support, and community services being arranged, but the planned discharge was later canceled by the physician due to medical reasons. The resident then experienced a significant change in condition and was transferred to a GACH. After the hospitalization, the GACH case manager contacted the facility about readmission, but the facility declined to accept the resident back on several occasions. The resident and a family member repeatedly requested contact with the facility because they wanted him to return there. The resident stated he wanted to return because he liked the facility, believed it could meet his needs, and was familiar with the staff and services. The family member stated the facility was chosen because it was closest to home and that she wanted him to return. The Administrator and DON stated the resident was not denied readmission because of behavior, care needs, equipment needs, or inability to provide care, but because the seven-day bed hold had expired and there were no available beds when the hospital requested readmission. However, census records showed available male beds existed after the transfer, and the DON confirmed the facility did not notify the resident, his family member, or the other SNF when beds later became available. The resident’s record also did not show a completed discharge plan before hospitalization or documentation that the discharge process had been completed. A DHCS Office of Administrative Hearings and Appeals document stated the appeal was granted and that the facility had not met the legal requirements to involuntarily discharge the resident.
Discharge Planning Failed to Ensure Resident-Specific Needs Were in Place
Penalty
Summary
The facility failed to implement an effective discharge planning process for multiple residents whose records were reviewed. For Resident #4, a discharge care plan was started after the resident chose to return to the community, but it was not developed by the interdisciplinary team, did not include the resident’s goals or treatment preferences, and did not identify the discharge location or post-discharge needs such as equipment or home health services. The plan was not regularly re-evaluated or updated as the resident’s situation changed, even though the resident later appealed insurance coverage decisions, considered long-term care Medicaid, and ultimately discharged home. Resident #4’s record also showed that a nurse practitioner documented the need for skilled nursing wound care, PT, OT, and a home health aide before discharge, but those services were not in place when the resident left the facility. Social services notes documenting discharge decisions and a referral for home health were entered late and were not added to the discharge care plan. After discharge, the resident was found on the floor in the apartment with vomit and urine, was hypotensive and hypothermic, and was diagnosed with traumatic rhabdomyolysis, acute kidney injury, and cellulitis in both lower legs. The ED record stated the resident reported wound care had not been provided since discharge. Similar discharge planning failures were identified for Residents #8, #9, and #10. Resident #8’s discharge care plan contained generalized interventions and was not updated to reflect the resident’s stated wish to go home or the specific equipment and services documented as needed, including skilled nursing, PT, speech therapy, OT, and a home health aide. Resident #9’s care plan also used generalized goals, did not reflect the resident’s discharge preferences, and did not address the need for skilled nursing, PT, OT, home health aide services, or the resident’s transfer difficulty noted during an IDT meeting. Resident #10’s discharge care plan likewise lacked resident-specific interventions and did not address the equipment and services needed after the resident’s bilateral lower-extremity amputations; the discharge summary omitted needed equipment and post-discharge services, and the resident was discharged without the hospital bed and other supports documented as needed.
Failure to Document Transfer Reasons and Prepare Residents for Facility Closure
Penalty
Summary
The facility failed to document the reason for a facility-initiated transfer in the medical record when it temporarily ceased operations and transferred residents to another facility. This affected all 16 residents who were moved out of the building. Review of the records for three residents showed no documentation in their progress notes explaining why the transfers occurred, even though discharge paperwork identified transfer to a sister facility. Resident #17 had diagnoses including major depressive disorder, dementia, and generalized anxiety disorder, and an MDS assessment showed moderately impaired cognition. The record showed the Executive Director spoke with the resident’s daughter/POA on the day of transfer, and the daughter agreed to the move, but the chart did not document the reason for the transfer. The daughter stated she received the discharge notice the same day the resident was moved. Resident #18 had diagnoses including senile degeneration of the brain, anxiety disorder, cognitive communication deficit, and dysthymic disorder, with severely impaired cognition and a legal guardian. The record showed the Executive Director spoke with the guardian on the day of transfer, and the guardian agreed to the move, but the reason for transfer was not documented. Resident #15 had diagnoses including psychosis, generalized anxiety disorder, dementia, and schizoaffective disorder, with moderately impaired cognition and a legal guardian. The record showed the Executive Director left a voicemail for the guardian about referrals for transfer, and the guardian later stated the first notice he received was an email saying residents would need to be relocated because of renovations. The Administrator and SSD confirmed the decision to close the building for renovations and that phone calls were made, but there was no documentation of those calls or of the transfer reason in the resident records.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization and failed to document the reason for discharge in the medical record. The resident involved had diagnoses including autism spectrum disorder, ADHD, OCD, generalized anxiety disorder, gastroparesis, seizures, and POTS. The record also showed intact cognition and no behaviors on the MDS assessment reviewed by surveyors. The resident became upset after being told she would have a roommate following a room change from a private room to a non-private room on the second floor. Facility notes documented that she repeatedly stated she did not want a roommate, said she would go to the hospital if she had to have one, attempted to remove the roommate’s belongings, and then called 911 stating she did not feel safe. She was sent to the hospital after expressing suicidal thoughts related to the roommate situation. Hospital records showed the resident remained inpatient for an extended period after being medically stable for discharge while placement was coordinated. The hospital documented that she did not want to return to the same facility and that if she were sent back she would kill herself. Later hospital notes documented that no inpatient psychiatric facility could accept her, that a safe discharge plan back to the nursing home had to be coordinated, and that the resident later stated she would return with support and would ask for help or call 911 if suicidal thoughts recurred. Facility leadership reported the final decision not to accept her back was made because of the suicidal ideations she expressed related to the facility, but the record contained no documentation explaining why her needs could no longer be met at the facility or the basis for the discharge.
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