F0627

D

Failure to Conduct and Document Safe, Coordinated Discharge Planning to Home

Kalamazoo, Michigan Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure a safe and orderly discharge for one cognitively intact resident who was dependent for transfers and required extensive assistance. The resident had diagnoses including aftercare following joint replacement, an artificial left knee joint, and hemiplegia/hemiparesis following a cerebral infarction affecting the left dominant side. His care plan identified him as a short‑term stay resident with good discharge potential and included interventions such as coordinating physician orders for discharge, arranging home health and equipment, evaluating discharge potential, and ensuring discharge to a safe environment with ongoing services. Despite these documented expectations, the facility did not carry out the planned interventions or document a comprehensive discharge needs assessment and plan in the medical record.

On 2/20, the business office and MDS staff received notice that the resident’s last covered day would be 2/22, and the resident was served a Notice of Medicare Non‑Coverage, which he signed. The social services staff member, who was new and minimally trained, believed the resident’s signature only confirmed understanding of appeal rights and did not recall discussing specific discharge plans, in‑home services, or outpatient therapy with the resident or his family. The family member reported believing that signing the form constituted an appeal and attempted to contact the insurer, but later learned the appeal had not been properly initiated. The facility’s business office manager discussed private‑pay costs with the family member and stated that, because there was no appeal on record, the resident would have to discharge or pay cash. The family member reported that social services did not assist with understanding or initiating the appeal process, despite the facility policy stating that residents would not be discharged while an appeal was pending and that social services would assist with appeals.

On the day of discharge, the family member was notified that the resident would be leaving within about an hour, expressed anxiety about the discharge, and reported not having transportation arranged. She requested to borrow a wheelchair and was denied any assistance from the facility. She then packed the resident’s belongings, called an ambulance, and left to prepare the home, arranging for neighbors to help when the resident arrived. Nursing staff reported that an LPN took over care shortly before the end of her shift, was told the resident was packed and ready to discharge, and did not have any discharge conversations with the resident or family; she later learned from a CNA that the resident had already left and documented that the ride did not receive the printed discharge paperwork. Therapy staff stated they were not informed in time to complete a discharge assessment or plan, and that the resident remained dependent with transfers and not safe to stand, with no discussions about the family’s ability to care for him at home. The discharge packet later found in a shred box contained incomplete documentation, including blank sections for method of transportation, discharge instructions review, staff and resident signatures, and contact information, and there were no progress notes documenting discharge discussions beyond a single note about the family’s anxiety. The family member reported receiving no caregiver education, no referrals for home health or outpatient therapy, and no assistance obtaining DME, and stated it took about a week after discharge to obtain a wheelchair and hospital bed while the resident remained in bed at home.

The facility’s written policy required that staff work with the physician to obtain adequate documentation for discharge, provide preparation and orientation to the resident and family, assist with appeals, and document the resident’s health status, discharge needs, and discharge plan, including services to be provided after discharge. It also required that residents not be discharged while an appeal was pending and that appropriate education and instructions be provided for a safe care transition. In this case, the NP’s last visit note did not mention discharge, and the recapitulation of stay and discharge documents lacked key clinical and contact information, special instructions, and confirmation that instructions were reviewed with the resident or representative. Interviews with the DON and other staff confirmed that social services were responsible for the discharge process and documentation, yet the record contained almost no documentation of discharge planning, no evidence of coordination of home services or DME, and no evidence that the resident and family were adequately prepared or oriented for discharge. These actions and omissions resulted in the resident being discharged to the community without a confirmed capable caregiver in place and without necessary DME available at the time of discharge.