F0627

D

Failure to Assess, Notify Physician, and Plan Safe Discharge Before Involuntary Removal to Homeless Shelter

Davenport, Iowa Survey Completed on 03-25-2026

Penalty

Fine: $10,225

Summary

The deficiency involves the facility’s failure to complete an updated assessment, notify the physician, and provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one resident. The resident had multiple significant diagnoses, including diabetes mellitus, heart disease, kidney insufficiency, malnutrition, anxiety disorder, depression, osteomyelitis, difficulty walking, and used a manual wheelchair. The MDS showed the resident was receiving opioid pain medication, antiplatelet medication, insulin, and anticonvulsant medication, and had an intact BIMS score of 15/15 with no documented behavioral symptoms toward others. The resident’s care plan included monitoring and documenting any risk for self-harm and signs and symptoms of depression, such as hopelessness, anxiety, sadness, and impaired judgment or safety awareness.

The facility issued an involuntary discharge notice on facility letterhead in February, citing endangerment to the safety of individuals in the facility and identifying a homeless shelter as the discharge destination, with an effective and expected transfer date one month later; this notice was unsigned. A second involuntary discharge notice, also unsigned, was issued in March, again citing the same regulatory authority and naming the same homeless shelter as the discharge destination, with the effective and expected transfer date on the same day. On the day of the March discharge, a progress note documented that an LPN attempted to administer medications and offer a pain pill, after which the resident became verbally aggressive, yelled, cursed, threatened the nurse, and blocked her between the meal tray cart and the med cart. The resident eventually moved his wheelchair, the nurse left, and the administrator was notified; the administrator then called the police, who came to the facility, spoke with the resident, and recommended discharge. The resident was given time to pack belongings, and the social worker and nurse attempted to provide discharge paperwork, which the resident refused to sign while continuing to yell.

Staff interviews revealed that nursing staff did not notify the physician about the discharge, and the social service director and administrator both confirmed that the physician was not notified. The social service director stated she had been working on transferring the resident since the fall, that the resident had multiple denials for placement, and that he had previously lived in a shelter before admission and lost his leg after an infection. She reported being instructed to give discharge papers to the homeless shelter, that the resident refused to sign, and that the administrator called the police due to the resident’s verbally aggressive behavior. The administrator stated she discharged the resident due to potential for violence and aggressive behaviors, acknowledged that she did not notify the State Agency or Ombudsman for either the 30‑day involuntary discharge notice or the emergent discharge, and stated she expected nursing to notify the physician but was unsure what a recapitulation of stay entailed. The facility’s own transfer and discharge policy required, in situations where a resident’s clinical or behavioral status endangers safety, physician documentation of the reason for transfer or discharge, a physician’s order for transfer or discharge, and completion of a discharge summary including a recap of the stay, final status, medication reconciliation, and a post‑discharge plan of care developed with the resident. These required assessments, notifications, and discharge planning elements were not completed or documented for this resident’s discharge to a homeless shelter following police removal from the facility.

Additional information from the Ombudsman and external records further described the circumstances surrounding the discharge. The Ombudsman reported receiving phone messages from the resident stating he was being kicked out because he allegedly pushed a pregnant staff member, which he denied, and that police had been notified; the Ombudsman also stated the facility had not reported the incident, police action, or discharge to the Ombudsman office, although a prior incident involving the resident hitting another resident had been reported the previous summer. A county sheriff’s inmate listing documented that the resident was booked for trespass on the same day as the discharge and released the following day. The administrator later stated she did not know the resident’s whereabouts after learning that another resident’s family member had picked him up after police release and taken him to the hospital, from which he was then discharged. Throughout these events, there was no documentation of an updated assessment, physician involvement, or a comprehensive, resident‑involved discharge plan as required by facility policy and regulation, nor evidence that the resident was adequately prepared or oriented for a safe and orderly discharge to the identified homeless shelter.