F0627

D

Improper Discharge to Emergency Department After Medicare Exhaustion Without Adequate Planning or Counseling

San Bruno, California Survey Completed on 12-30-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement an effective discharge planning process and to ensure an orderly, appropriate discharge for one of three sampled residents. The resident was admitted with multiple chronic conditions, including COPD with acute exacerbation, centrilobular emphysema, gait and mobility abnormalities, unsteadiness, dysphagia, CKD, and urinary retention. A discharge care plan was initiated but left the discharge destination preference blank and did not identify specific discharge problems, goals, or interventions. The care plan was not revised or updated to reflect any discharge preferences of the resident or the resident’s representative.

As the resident’s Medicare Part A coverage approached exhaustion, the facility issued a Notice of Medicare Non-Coverage indicating the end date of coverage. Provider documentation around this time was inconsistent: a practitioner note stated the resident was medically stabilized but not strong enough to return home and that discharge planning was pending therapy progress, while a physician discharge summary documented a planned discharge home with home health services and a stable condition. A physician order later specified discharge home with RN, PT, OT, HHA, and SW services. However, the Notice of Proposed Transfer/Discharge and the facility’s Discharge Summary and Post-Care Instructions instead identified a plan to send the resident to a VA location to check benefits eligibility and assign a social worker for placement under a VA program, with transportation by a friend.

On the actual day of discharge, the social worker documented that the resident would be brought to the VA emergency room so that a social worker, VA PCP, and benefits eligibility could be arranged, citing exhaustion of Medicare days at the current and previous SNFs. Nursing documentation recorded that the resident left via a transportation company but did not document the discharge destination or home health information as ordered by the physician. Interviews with the DON and ADON confirmed there was no significant change in the resident’s condition and that the resident was stable on the day of discharge, indicating no medical necessity for an emergency transfer. The social worker and VA staff confirmed that the resident was taken directly to the VA emergency department without an appointment and without an apparent medical reason, and VA staff reported telling the social worker that the resident could not be brought in “for no reason.”

The resident’s representative reported not being informed about the option to apply for Medi-Cal or to pay privately to remain at the facility and described the discharge as rushed, with nothing prepared in advance, despite the social worker’s knowledge that the resident had no place to stay because his prior apartment had been demolished. VA staff further stated that no Medi-Cal application had been filed for the resident and characterized the discharge as occurring after the resident ran out of 100 Medicare days. Review of the clinical record showed a lack of documented care coordination and discharge planning discussions with the interdisciplinary team, the resident, and the representative, and the discharge documentation from medical provider, social services, and nursing contained conflicting information. These actions and omissions were inconsistent with the facility’s own transfer/discharge policies, which require that residents not be transferred unless necessary for their welfare, that appropriate notice and documentation be provided, that residents receive assistance with third-party payment applications, and that residents who continue to need LTC services be offered the option to remain privately or with Medicaid assistance.