F0627

D

Failure to Obtain Physician Documentation for Involuntary Transfer/Discharge

Lansing, Michigan Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a physician documented the necessity of a resident’s transfer/discharge based on safety concerns. The resident was admitted with multiple diagnoses including a left leg fracture, epilepsy, anxiety disorder, depression, schizophrenia, and PTSD, and was documented as cognitively intact on the MDS BIMS assessment. On one day, social services and the nursing home administrator attempted to issue immediate involuntary discharge paperwork citing repeated threats toward staff and other residents, and the resident requested appeal paperwork but refused to physically accept the documents. Nursing notes indicated that police came to the facility after the resident called 911, and the DON gave the police the involuntary discharge letter. The resident was documented as being aware he needed to leave the next day, based on what the police told him.

The following day, nursing documentation showed the resident was unexpectedly discharged via police car to the ED under a court-appointed petition. Multiple staff interviews confirmed that the facility was in the process of an involuntary discharge and had not yet received State Agency approval. The NHA, DON, ADON, SSD, and an RN all reported that when the hospital called seeking to return the resident, facility staff stated the resident would not be readmitted and instead could go to a local motel, and the hospital ultimately discharged him to the community when he refused the motel. The involuntary discharge forms and notice cited endangerment to the safety and health of others due to the resident’s clinical/behavioral status, but review of the medical record revealed there was no physician documentation that the transfer/discharge was necessary for these safety reasons.