F0628

D

Failure to Document Required Transfer/Discharge for a Resident Returned to Hospital

Pontiac, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The facility failed to follow its required transfer/discharge process and documentation requirements for one resident who was discharged without a proper discharge notice or required elements in the medical record. The facility’s Discharge/Transfer Policy, revised 1/25, requires guidelines for appropriate discharge and transfer procedures and specifies that a written or telephone order from the attending physician is needed for a resident’s transfer or discharge. The resident was admitted to the facility on an unspecified date, and later, hospital notes dated 2/23/26 show the resident was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. The facility reported that during a background check it was discovered the resident had a sexual offense and could not be admitted, and the facility attempted to find alternative placement but was unable to do so, then returned the resident to the ED for nursing home placement after receiving a CHIRP (Criminal History Information Response Process) result dated 2/23/26 indicating the resident was listed as a sexual offender. The resident’s Power of Attorney reported being told by the facility that the resident was being sent back to the hospital due to the background check results, and the Social Service Director confirmed the CHIRP findings and the decision to send the resident back to the hospital. The Administrator confirmed that no discharge documentation or discharge orders were found in the resident’s chart, indicating the required transfer/discharge process was not completed or documented.