F0627

D

Failure to Readmit Hospitalized Resident and Provide Required Written Discharge Notice

Milford, Michigan Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to permit a resident to return following a hospital transfer and failure to provide required written discharge notices. The resident had been admitted with multiple cognitive and behavioral diagnoses, including severe vascular dementia with behavioral disturbance, other dementia with behavioral disturbance, mild cognitive impairment, and age-related cognitive decline. The admission MDS documented severe cognitive impairment, behavioral symptoms directed toward others and not directed toward others that significantly interfered with care and activities, behaviors that put others at significant risk of physical injury and significantly disrupted the living environment, and wandering that placed the resident at significant risk or intruded on others. Hospital records available to the facility before admission described a long history of dementia, agitation, prolonged behavioral outbursts, aggression, wandering, incontinence, and prior placement difficulties, confirming that the facility had access to extensive information about the resident’s behavioral history when it accepted the admission.

After admission, facility progress notes documented multiple incidents of exit-seeking and physical behaviors such as swinging, kicking, spitting, and swearing, for which staff obtained additional IM psychotropic medications. On the night of the transfer, the resident reportedly assaulted staff, including a one-to-one staff member, and was sent to the hospital. A nurse’s note from the early morning hours documented that EMS attempted to return the resident, but nursing staff informed EMS that the facility could not provide care due to the resident’s behavior and that there were orders for a “do not return” because the facility was unable to meet the resident’s needs related to aggressive and combative behavior. The same note indicated that hospital staff called to inquire why the resident was refused, and the nurse explained that the resident had again attacked a staff member and that the DON and Administrator had ordered that the resident not be accepted back.

Interviews with staff confirmed that the decision not to readmit the resident was made by facility leadership and communicated verbally. The social services staff member stated they were not involved in the admission decision or the later decision not to allow the resident to return, but understood that the refusal was due to exit-seeking and aggression and that the facility had discussed more appropriate locked memory care placement with the family. The DON reported that when the hospital called to ask if the resident could return, the facility said no and that they had a phone conversation with the ombudsman about not accepting the resident back, but there was no written notification. A nurse reported telling the resident’s wife by phone that the facility would not accept the resident back because the abuse that night was very dangerous and that their orders from the DON and Administrator were to send the resident out with a “no return.”

Record review showed that the facility completed a “Facility-Initiated Transfer for Nursing Homes” form citing that the resident’s behavioral needs could not be met and describing combative behavior with staff, but the transfer packet documentation was left incomplete, including missing sections that required a second nurse witness signature. The facility’s policies on bed hold, hospital and therapeutic leave, readmission, and notice of transfer or discharge were reviewed. The bed hold/readmission policy stated that the facility would hold a bed for 10 days for emergency medical treatment and would readmit a discharged resident with an expectation of return unless the discharge was necessary for the resident’s welfare or the safety of individuals in the facility was endangered due to the resident’s clinical or behavioral status; this policy referenced obsolete federal regulations and had not been updated since 2017. The notice of transfer or discharge policy described requirements for facility-initiated transfers and involuntary discharges, including use of specific forms (FIT-100 and ITD-100), provision of written notice to the resident or representative with appeal information, submission of notice to the state agency, and written approval of transfer or discharge plans, but the facility did not provide evidence that these written notices and processes were followed for this resident. The Administrator acknowledged that the ombudsman had only been notified by phone, that written notification was not provided, that the local ombudsman information in facility materials was outdated, and that the relevant policy had not been updated.