F0627

D

Failure to Develop and Implement Appropriate Discharge Planning and Readmission for Hospitalized Resident

Los Angeles, California Survey Completed on 02-03-2026

Penalty

No penalty information released

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.