Failure to Develop and Implement Appropriate Discharge Planning and Readmission for Hospitalized Resident
Summary
The deficiency involves the facility’s failure to develop and implement an appropriate discharge plan and readmission process for a resident who had been transferred to a general acute care hospital (GACH) for psychiatric evaluation and was not permitted to return. The resident was initially admitted with encephalopathy, epilepsy, dysphagia following a CVA, and severe cognitive impairment, and was largely dependent on staff for ADLs. The admission record did not show a psychiatric diagnosis, but the resident had an order for PRN quetiapine for agitation and was documented as lacking capacity to understand and make decisions. The care plan and an IDT conference shortly after admission identified a discharge goal of returning home with family when able, with the facility offering to assist with home health and DME arrangements or alternative placement options once the MD cleared discharge. After admission, the resident became physically combative with staff, including kicking, punching, and disrobing, and was placed on 1:1 observation. This escalation led to a physician order to transfer the resident to GACH on a 5150 hold. The facility considered this transfer a proper discharge due to the change in condition. The facility’s policies on readmission and transfers/bedholds stated that residents discharged to the hospital would be given priority for readmission and that the facility would develop discharge planning procedures focusing on discharge goals and preparation for transition to post-discharge care. However, following the transfer, the facility did not complete or revise a discharge plan addressing the resident’s post-hospital needs or potential return, despite the previously documented goal of discharge home with family and the facility’s stated role in coordinating services and placement. GACH case management notes documented that the resident had been decannulated and was ready for discharge for at least three months, and that multiple referral packets and updated clinical information were faxed to the facility and other SNFs over several months. On at least one follow-up call, the facility’s admissions coordinator confirmed receipt of the referral and stated the resident was not appropriate for readmission because of the prior 5150 transfer, even after being informed by the GACH case manager that the resident was calm, not on restraints, and did not require a sitter. The DON acknowledged awareness of a referral in mid-December, stated that the information indicated the resident was still restrained, and confirmed he did not contact GACH to verify the resident’s current status. The DON maintained that the facility would not readmit the resident and did not address whether hospitalization was an appropriate long-term disposition, despite facility policies requiring priority readmission and comprehensive discharge planning. These actions and inactions resulted in the resident remaining in the hospital for months after being cleared for discharge. The facility’s own policies titled “Readmission to the Facility” and “TRANSFERS / BEDHOLDS AND DISCHARGES – OUT OF FACILITY” required that residents discharged to the hospital be given priority for readmission upon bed availability and that discharge planning procedures focus on the resident’s discharge goals and preparation for transition to post-discharge care. Despite these policies, the facility did not reassess or update the resident’s discharge plan after the psychiatric transfer, did not engage in documented IDT discharge planning with the hospital’s input, and did not coordinate or facilitate the resident’s return or alternative placement once the resident was clinically ready for discharge. Instead, the facility relied on the fact of the prior 5150 transfer as the basis for refusing readmission, without documented individualized assessment of the resident’s current condition or needs, and without documented communication with GACH to clarify the resident’s status. This lack of effective discharge planning and refusal to readmit contrary to policy formed the basis of the cited deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cognitive and mental health diagnoses, who had previously expressed a desire to remain in LTC, exhibited an episode of aggressive behavior that led to an involuntary emergency mental health examination and transfer to a hospital. The facility’s documentation shows the DON and provider described the behavior as dangerous and initiated the transfer, but the clinical record lacked evidence that a bed-hold policy was offered at the time of transfer. Hospital records indicated the resident was calm, oriented, medically cleared, and did not meet criteria for continued involuntary psychiatric placement, and he was deemed ready for discharge. When the hospital sought to return the resident, the DON, Administrator, and Admissions Director reported that facility leadership and regional management decided not to accept him back or to any sister facilities, without documented basis for discharge, resulting in his placement at another nursing home approximately 73 miles from his family.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
A resident with dementia, TBI, and prior severe cognitive impairment later became able to clearly express that she wanted to go home with Family Member D, but the care plan did not show updated discharge goals once she stabilized. Staff across nursing, Social Services, Activities, and administration knew she repeatedly voiced this preference, yet the chart did not show action to support her discharge wishes. The record also showed confusion about an MPOA that was not signed by the resident and no physician certification that she lacked competence to make her own health care decisions.
Failure to Allow Return After Hospital Transfer: A resident was transferred to the ER for altered mental status and increased confusion, but the facility did not provide a transfer/discharge notice and did not allow the resident to return after the acute hospitalization. The DON stated the decision not to permit return was financial, while the business office manager believed it was due to insufficient staffing. The facility policy stated residents transferred to acute care will be permitted to return upon discharge, and not permitting return constitutes a discharge.
Two residents experienced inappropriate and poorly managed discharges. One resident with acute PE, acute respiratory failure, DM2, affective disorder, and Parkinson’s disease was discharged to an ALF with transportation arranged through an outside company, but the transport request was later canceled and not confirmed by staff. After being moved from her room to an activities area and repeatedly told her ride was coming, she left the building in her wheelchair without staff awareness and was later found on the roadside and taken to the ED. Another resident with degenerative disc disease, DM2 due to other mental disorder, and adjustment disorder was transferred to another nursing home without a documented medical reason, without a 30‑day written notice, and with a discharge order lacking reason, level of care, or assistance needs. He reported being told he would be evicted if he did not choose a facility, refused to sign the transfer notice, and ultimately was sent to a different nursing home than the one he chose, later having to arrange and pay for his own transportation after the receiving facility would not take him back.
A resident with polyneuropathy, DM2, UTI, and HTN was discharged without a reconciled med list, discharge paperwork, or her prescribed meds, including pain meds. The discharge summary had no current meds listed, the signed discharge instruction form was not found in the chart, and the resident reported she went overnight without meds until the discharge planner delivered them the next morning. Staff accounts conflicted about whether discharge instructions and meds were reviewed and provided.
Failure to Permit Resident’s Return and Inadequate Discharge/Bed-Hold Process After Psychiatric Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospitalization and involuntary mental health evaluation, and failure to follow required transfer, discharge, and bed-hold procedures. The resident had been admitted with diagnoses including problems with social environment, mild cognitive impairment due to unknown origin, a condition with mixed features, and an adjustment disorder with mixed anxiety and depressed mood. A quarterly MDS showed intact cognition and no physical or verbal behavioral symptoms directed toward others at that time. The resident’s care plan documented that he wished to remain in LTC at the facility and identified goals related to managing verbally aggressive behaviors such as yelling at other residents. Progress notes show that on one day the provider documented that the resident had been increasingly agitated, responding to internal stimuli, refusing medications and care, and exhibiting aggressive and impulsive behavior that was considered dangerous to himself. The provider stated that the resident had failed all staff interventions to keep him safe and required a higher level of care, leading to an involuntary emergency mental health examination. The DON documented in a late entry that the resident had a burst of anger with uncontrolled behavior, including screaming, kicking the entrance door of his room and creating a hole in the wall, and kicking another wall near his TV, also creating a large hole. Law enforcement and EMS were notified, a Baker Act order was presented, and the resident was transported from the facility under this order. The DON noted that the behavior was frightening to staff and other alert residents and that the resident needed to be out of the facility for the safety of staff and residents. The clinical record did not contain documentation that a bed-hold policy was offered to the resident or his representative at the time of transfer. The hospital record shows that the resident was admitted under involuntary commitment for evaluation of mental health concerns following reported aggression at his memory care facility. On admission to the hospital, he was calm, cooperative, and oriented, with no acute distress, and denied suicidal or homicidal ideation. He was medically cleared in the ED, and a psychiatric evaluation, including telemedicine consultation, determined that he did not meet criteria for involuntary inpatient or outpatient psychiatric placement; the Baker Act and associated safety protocols were discontinued, and he was cleared for discharge from a psychiatric standpoint. Case management and social work became involved because the prior SNF refused to accept him back, and alternative placement options were explored. The DON confirmed there was no documentation that a bed hold was offered and stated that the resident’s emergency contact had declined the bed hold, and that when the resident was ready for discharge from the hospital, the facility refused to take him back because she believed he would be better off in a group home due to his age and volatile behavior. The emergency contact reported that, because the facility refused readmission, the resident was placed in another nursing home approximately 73 miles away, and she expressed a desire for him to return to the original facility. The Admissions Director stated that several days after the transfer, the hospital notified the facility that the resident was ready to return, but her regional leader instructed her not to accept the resident and not to admit him to any sister facilities. The Administrator acknowledged that a bed hold was not offered and that there was no documentation of the basis for the resident’s discharge, and stated that the regional team decided not to allow the resident to return based on information from facility staff.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The identified resident's #2 discharge documentation was reviewed. Resident no longer resides in facility. 2. A 100% audit of all transfers/discharge forms and bed hold within the past 30 days was conducted to verify compliance with F627 requirements. Any discrepancies identified were immediately corrected, including issuance of proper notices and documentation updates. Residents under consideration for transfer/discharge will be reviewed to ensure full compliance with regulatory requirements. 3. A discharge checklist was developed to ensure all required steps are completed prior to any transfer or discharges. Education completed with all licensed nurses on discharge checklist and transfer/discharge forms and bed hold education. All planned discharges will be reviewed by IDT prior to discharge to ensure compliance. 4. Social Services Director or designee will conduct 4x/week audits of all transfers/discharges for 4 weeks, then, 3x/week x 4 weeks; then, 2x/week x 4 weeks; then, weekly x 4 weeks to ensure regulatory compliance. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until committee determines substantial compliance has been met.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Discharge planning did not reflect resident’s expressed home discharge preference
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident whose condition improved and who was able to express her discharge preference. Resident #40 had diagnoses including traumatic subdural hemorrhage with loss of consciousness, Alzheimer's disease with late onset, non-Alzheimer's dementia, and traumatic brain injury. Her quarterly MDS reflected severe cognitive impairment with a BIMS score of 06, but other records and staff interviews documented that she later became able to communicate her needs and wants, participate in activities, and state that she wanted to go home with Family Member D to her home in North Carolina. The resident's care plan identified that she was resistive to care because she wanted to go home with Family Member D, and the goal focused on cooperation with care. However, the care plan did not show discharge plans once she stabilized and could make her preferences known. Facility records and interviews showed that staff were aware she repeatedly expressed a desire to discharge home with Family Member D, and multiple staff members stated she could verbalize her wishes clearly and that her cognition improved over time. The Administrator note documented that Family Member D told the facility she could provide 24/7 care, while Family Member B, listed as MPOA and responsible party, did not agree with the discharge. The record also showed confusion about the validity of the MPOA and who could make discharge decisions. The MPOA document in the chart was not signed by Resident #40, and the physician record did not show certification that she lacked competence to make health care decisions for herself. Social Services, nursing leadership, and the Administrator all acknowledged that Resident #40 expressed a desire to return home with Family Member D, but the EMR did not show action by Social Services, charge nurses, ADON, DON, or the Administrator to assist with honoring those wishes. The resident was ultimately discharged home with Family Member D after law enforcement was contacted and the physician was notified.
Failure to Allow Return After Hospital Transfer
Penalty
Summary
The facility failed to ensure resident #82 was allowed to return after an acute hospitalization. A progress note dated 3/11/26 at 8:33 PM documented that the resident was transferred to the hospital emergency room for altered mental status and increased confusion. The medical record showed no evidence that a transfer/discharge notice was provided at the time of transfer. A discharge MDS assessment showed the resident’s return to the facility was anticipated and that the discharge was unplanned, with a discharge status of Short-Term General Hospital (acute hospital, IPPS). Interviews confirmed the resident did not return to the facility after the hospital transfer. The DON stated on 5/7/26 at 9:45 AM that the decision not to allow the resident to return was financial, and also confirmed that no discharge notice was provided after transfer and that the facility did not assist in finding alternate placement. The business office manager stated on 5/7/26 at 10:54 AM that the resident was not allowed to return following the hospital transfer, although he believed the reason was insufficient staffing. The facility policy stated that residents transferred to acute care will be permitted to return upon discharge and that not permitting a resident to return following hospitalization constitutes a discharge.
Failure to Ensure Safe and Properly Planned Discharges for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and properly planned discharges for two cognitively intact residents, resulting in noncompliance with federal requirements for transfer, discharge, and discharge planning. For the first resident, who had diagnoses including acute pulmonary embolism, acute respiratory failure, type 2 diabetes, unspecified affective disorder, and Parkinson’s disease without dyskinesia, the facility arranged same-day transportation through an outside transport company to return the resident to an assisted living facility (ALF). The Social Services Director documented that transportation was scheduled for late afternoon, but the clinical record did not contain documentation of the actual pickup date and time. The transport company later reported that the request was canceled because it did not meet their required notice time. The resident was removed from her room and placed in the activities room to wait, and staff repeatedly told her that transportation was on the way. As the day progressed, key administrative staff left the building while the resident continued to wait. The ADON reported that when he left around early evening, the resident was at the nurse’s station asking about her ride, and he told her that the ALF was coming to pick her up. He later received text messages from an RN indicating that the resident was upset and wanted to leave, followed by another message that she had left. The NHA stated that staff assumed the resident had left with her ride, even though no one actually saw her get into a vehicle. The resident reported that she had been waiting for transportation for several hours, that “the big wigs left,” and that the night nurses did not know what to do with her. She stated she eventually pushed open the door and left the facility in her wheelchair without staff awareness. She described self-propelling in the road, not knowing the route to her ALF, and being found on the side of the street by passersby who called 911. An ER physician note documented that she reported waiting all day, becoming tired of waiting, leaving, and being found on the side of the street in her wheelchair before being transported to the ER. For the second resident, who had diagnoses including degenerative disc disease, type 2 diabetes due to other mental disorder, and adjustment disorder with mixed anxiety and depressed mood, the facility discharged him to another nursing home in a different county without a documented medical reason that met regulatory criteria for transfer or discharge. A psychiatric progress note described the resident as unstable with episodes of agitation related to situational concerns about being transferred to a new nursing home. The discharge summary indicated he was being discharged to another nursing home, and a discharge order was entered without specifying the reason for transfer, level of care, or assistance needed. The written transfer and discharge notice given to the resident stated that his health had improved sufficiently so he no longer needed the services of the facility, but the resident refused to sign the form. The Social Services Assistant confirmed that the resident was not given a 30-day written notice and only received an undocumented verbal notice of about three weeks. The NHA stated that the resident was transferred because the facility was transitioning to more short-term beds, and the ADON confirmed there was no medical reason for the transfer, that the resident still needed LTC, and that the receiving facility did not provide any additional care beyond what the discharging facility could provide. The resident reported he had been told he would be evicted if he did not choose a place, that he selected one facility but was transported to another, and that after subsequent hospitalization the new facility would not readmit him, leaving him to arrange and pay for his own transportation and live in hotels.
Plan Of Correction
F627 Appropriate Discharge (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #1 was discharged from the facility. On , Resident #2 was discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By , The NHA/Designee completed education with current social services staff and IDT team members on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. Newly hired Social Services staff and IDT team members will be educated on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. NHA/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The DON/Designee will audit 5 random discharged residents to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Discharge Process Failed to Provide Reconciled Medications and Paperwork
Penalty
Summary
The facility failed to ensure a safe discharge process for a resident with polyneuropathy, type II diabetes mellitus, a urinary tract infection, and essential hypertension. The resident’s discharge MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and the discharge summary noted she had received scheduled and PRN pain medication within the last 5 days and had experienced occasional mild pain. Her care plan included monitoring a raised bruise area to the right shin and giving medication per order with monitoring for relief. At discharge, the resident was sent home at 6:56 p.m., but the discharge summary’s Current Medications section contained no entries. The discharge instruction form indicated that medication education was reviewed, prescriptions were provided, and the resident acknowledged receipt of the current reconciled medications, yet no reconciled medication list was present on the form and no scanned copy of the signed form was found in the chart. The facility’s discharge documentation also reflected items such as medications called into the pharmacy, follow-up appointments, and instructions to share the medication list with health care providers, but the record did not contain the actual reconciled medication list. The resident reported she did not receive discharge paperwork, belongings, or medications when the ride arrived, and she stated she was told she could not take her medications home because they were narcotics. She said she went the remainder of the evening and the following morning without her prescribed medications, including pain medications, and did not receive them until the next morning when the discharge planner delivered them to her home. The administrator confirmed the medications were not prepared at the time of discharge and that the facility could not produce a reconciled list of medications provided to the resident. The discharge planner and nursing staff gave differing accounts of whether discharge paperwork and medications were reviewed and provided, and the facility’s transfer and discharge policy required medication reconciliation, resident orientation for discharge, and assistance with transportation arrangements.
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