Unsafe Discharge Without Confirmed Acceptance by Receiving Facility
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was transferred to another skilled nursing facility without confirmed acceptance from the receiving facility. The resident had a history of traumatic brain injury, hemiplegia/hemiparesis, and a BIMS score of 9, indicating moderately impaired cognition, though they were able to make themselves understood and understand others. The resident’s admission MDS documented difficulty recalling the correct year, month, and day of the week. A Notice of Proposed Transfer/Discharge dated 1/2/26 stated the transfer or discharge was appropriate because the resident’s health had improved sufficiently so that they no longer required the services provided by the facility. Interviews revealed that the resident’s responsible party requested transfer to another nursing home because they did not want the resident to remain at the current facility and wanted more rehabilitation therapy. The SS staff member stated the responsible party did not like the facility and confirmed that the facility did not receive confirmation from the receiving facility of the resident’s admission before discharge and transfer occurred. The DON stated the facility had provided physical, occupational, and speech therapy as ordered and that a referral for more therapy had been denied. The Administrator reported that a letter of admission agreement was sent to the receiving facility but could not provide documentation that admission had been confirmed prior to discharge. As a result, the resident was not accepted for admission at the receiving facility and was sent to a GACH emergency department. The facility’s policy on facility-initiated transfer or discharge stated that residents have the right to remain in the facility and that such transfers must meet specific criteria and require notification, orientation, and documentation.
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