F0627

D

Failure to Readmit Hospitalized Resident and Follow Required Transfer/Discharge Procedures

Flint, Michigan Survey Completed on 03-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to permit the readmission of a long‑term care resident following hospital evaluation and discharge, resulting in the resident remaining in the hospital while alternate placement was sought. The resident had been admitted to the facility with diagnoses including aphasia, right‑sided hemiplegia/hemiparesis after an intracerebral hemorrhage, dementia with agitation and hallucinations, major depression, a need for assistance with personal care, and a history of suicidal behavior. An MDS assessment showed a BIMS score of 11/15, indicating moderate cognitive impairment. The facility’s own transfer/discharge guideline states that residents have the right to remain in the facility and that transfer or discharge must follow specific notice, preparation, and appeal procedures, including notification to the State Long‑Term Care Ombudsman.

In the days leading up to the refusal of readmission, the resident exhibited behavioral symptoms. Staff reported that the resident was sometimes combative, grunted loudly, and became frustrated when not understood. On one occasion, the resident kicked a conference room door where management was meeting, shook his fist at staff and other residents, and yelled in the dining area. The NHA stated that the resident could not be threatening other residents and needed to be sent out for a behavior evaluation. A transfer assessment dated for that episode cited increased behaviors, refusal of medication, being physical with staff, and being inconsolable and non‑compliant, although the unit manager later clarified that aside from the fist‑shaking gesture there was no physical contact with staff. The resident was sent to the hospital and returned the same day, and staff reported no new behavioral concerns upon his return.

Subsequently, the resident was again in the dining area, became visibly upset, and yelled out a family member’s name. The regional director of clinical operations (RDC) interacted with him, during which he calmed and engaged in coloring and discussion about his communication frustrations. Later that day, while waiting for the elevator, the resident punched another resident in the arm as two residents exited the elevator; the struck resident was assessed and found to have no injuries. The unit manager and RDC reported that the medical director petitioned for a full psychiatric evaluation and the resident was sent to the hospital. However, the hospital social worker stated there was no petition sent from the facility and that on both behavioral presentations the resident was medically and psychiatrically evaluated and did not meet criteria for hospitalization. The hospital discharged the resident back to the facility, but EMS reported they were not permitted to enter the building with him and had to return him to the hospital.

Multiple facility staff acknowledged that management had communicated that the resident was not to be accepted back. A nurse reported being told by the unit manager that if the ambulance brought the resident back, staff were not to accept him. The unit manager confirmed that when the hospital called late at night to report they had been told the facility would not accept the resident back, she referred them to upper management and later stated that staff were aware per the NHA that the resident was not to return. The NHA acknowledged that the resident had the right to return but stated that higher‑ups were concerned about safety and that other residents were afraid to come out of their rooms because of the resident’s behaviors. The facility liaison reportedly told the hospital that higher‑ups said the resident could not return because he was a danger to residents and staff. Despite repeated hospital requests, no formal eviction or discharge notice was provided.

The resident’s family member reported being told that the resident could not come back and that they needed to collect his belongings, and she stated that his discharge did not align with his long‑term placement goals and that she wanted him to remain near her. The social worker at the facility confirmed that the resident’s discharge plan prior to these events was for him to remain at the facility because his daughter could not care for him at home. She also acknowledged that the resident attempted to readmit from the hospital and was not allowed to return due to behavior, and that she did not notify the Ombudsman. Documentation in the resident’s chart lacked a transfer assessment or progress note for the later hospital transfer, and the RDC acknowledged that no such note had been entered. The hospital social worker documented that the patient was appropriate for discharge back to the facility, but because the facility refused to accept him, he was subsequently admitted to the hospital. This sequence of actions and omissions shows that the facility did not follow its own transfer/discharge guideline and did not permit the resident’s readmission after hospital discharge, thereby failing to ensure a safe and appropriate discharge consistent with the resident’s needs and preferences.