F0627

G

Unsafe Discharge Home Despite Resident and Family Objections

Kalamazoo, Michigan Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a cognitively intact female resident with multiple serious medical conditions, including left lower limb cellulitis, diabetes, morbid obesity, peripheral atherosclerosis with gangrene, heart disease, hypertension, anemia, anxiety, and severe chronic kidney disease. Her care plan documented that she planned to discharge home, with interventions to involve her and her family in discharge planning, coordinate home care agencies and community supports, and provide written instructions for a safe return to the community. Despite this, the discharge planning process did not adequately address her and her family’s expressed concerns about the safety and feasibility of returning home, particularly regarding access to the home and the availability of care.

In the days leading up to discharge, the resident, her family member, and multiple staff members reported significant distress and concern about the planned discharge home. The resident’s MDS showed she was cognitively intact, and she repeatedly stated she could not go home and could not get into the house, which was corroborated by a physical therapy note documenting that she was very emotional and requesting to stay longer. The family member told staff, including the DON, that the resident was in no condition to be discharged and that there was no way to get the resident into the home due to an electric wheelchair blocking the door and the resident’s own wheelchair being too wide. Nursing staff, including RNs, reported that the resident was distraught, crying, and verbalizing that she could not care for herself and would have to call 911 after discharge. Staff nurses expressed that they did not feel safe discharging her and one RN refused to sign the discharge paperwork because she felt it was inappropriate.

Financial and insurance issues were central to the decision to proceed with discharge despite these concerns. The business office manager reported that the resident’s managed insurance coverage ended with a last covered day and that a Notice of Medicare Non-Coverage was issued and appealed, with the first appeal rejected. The facility informed the resident and family that, without a secondary payer source, continued stay would require private payment in advance, and the DON and regional director stated that facility policy did not allow acceptance of personal checks for room and board, requiring cash, debit/credit card, or certified check. The family member attempted to pay the requested amount with a personal check but was told it would not be accepted and was unable to obtain a certified check before the scheduled discharge. Despite ongoing appeals and later confirmation that a second-level appeal had been approved, the facility proceeded with the planned discharge when transportation arrived. On the day of discharge, multiple staff and the transport driver observed that the resident was upset, crying, and apprehensive, and upon arrival at home, the wheelchair would not fit through the door and the path inside was blocked, leading the family member to call an ambulance and the resident to be rehospitalized. These events demonstrate that the facility did not ensure the discharge plan met the resident’s needs and preferences or that she was prepared for a safe transfer home, as required by its discharge planning policy.