F0627

D

Failure to Readmit Hospitalized Resident Under 30‑Day Discharge Notice

Charlotte, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to readmit a resident after a hospital transfer while the resident was under a 30‑day discharge notice. The resident had dementia with behavioral disturbances, dysphagia, and chronic kidney disease, was severely cognitively impaired, and required staff assistance with all ADLs. The admission MDS indicated no coded behaviors and documented that the resident wished to remain in the facility long term. Care plans created earlier in the month identified the resident’s need and preference for long‑term care placement and documented risks for wandering and elopement, with interventions such as purposeful activities, de‑escalation strategies, and reorientation.

On 2/26, the facility issued a 30‑day discharge notice stating that discharge was necessary for the resident’s welfare and that his needs could not be met in the facility, listing his home address as the discharge location. A revised notice the same day added a handwritten note that discharge could occur sooner if appropriate placement was found at a named memory care facility, while still listing the home address as the discharge location. The resident’s family reported that the memory care facility that assessed the resident was not acceptable to them, and they were working to find another placement. Despite this, the 30‑day discharge notice remained in effect.

On 2/28, Nurse #5 documented that the resident had increased confusion, agitation, wandering, unsteady gait, and was at one point falling into the wall while walking. The nurse reported that the resident attempted to swing at staff, contacted the medical provider, obtained an order to send the resident to the ER, and notified the responsible party. Hospital records show the resident was brought to the ER for abnormal gait and increased agitation and was medically cleared for discharge later that day, with documentation that he was not an imminent threat to himself or others. When the hospital attempted to return the resident to the facility, the Former DON told the Hospital Case Manager that the resident would not be returning due to safety concerns and documented that the Regional Ombudsman was involved.

Email communications among the social worker, Administrator, Former DON, and Regional Ombudsman show that the social worker sent the amended 30‑day discharge notice to the Ombudsman on 2/28 after the resident’s transfer. The Regional Ombudsman later relayed that the Hospital Case Manager reported the resident was in the ER, not admitted, and that unless the family chose to move him directly to memory care, the facility was obligated to readmit him and provide a sitter until transfer. The Administrator acknowledged that the resident had been accepted to memory care and that the family was considering options, and later indicated that the family wanted to appeal the 30‑day discharge notice. When the Ombudsman asked if the resident would return to the facility, the Administrator suggested he would, but the Former DON responded that the facility was not able to take him back.

Hospital records and interviews confirm that the resident remained in the ER from 2/28 until 3/6 because the facility would not readmit him while the 30‑day discharge notice was in effect. The Hospital Case Manager stated that when the facility was contacted on 2/28 to readmit the resident, the Former DON refused. The Regional Ombudsman stated she informed facility management of the resident’s right to return and that the Former DON maintained the facility would not readmit him. The resident was ultimately discharged from the hospital to his home with a family member and later placed in another memory care facility. These actions and inactions demonstrate that the facility did not ensure the resident’s transfer and discharge were consistent with his needs and preferences and did not readmit him after hospital evaluation despite his being medically cleared and under an active 30‑day discharge notice.