F0627

D

Failure to Plan and Document Safe, Goal-Directed Transfers and Discharges

Chillicothe, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document sufficient preparation and planning to ensure safe and orderly transfers and discharges, and to ensure the discharge planning process addressed each resident’s discharge goals and needs. For one resident with alcohol dependence in remission, COPD, and rheumatoid arthritis, the care plan identified a history of substance abuse and anticipated that he would purchase and drink alcohol at the facility, with interventions to monitor for misuse and notify the physician if there were concerns. His social service evaluation and care plan documented that he was admitted for skilled services and planned to discharge to the community with his daughter, with a goal of a safe transition back to the community and interventions including involving home care agencies and community supports and providing written discharge instructions.

On a later date, nursing notes documented that this resident fell in the hallway, hit his head on the medication cart, and was under the influence of alcohol, with an abrasion to his left eyebrow. He was alert and oriented and refused transfer to the hospital, and neuro checks were initiated. Shortly afterward, the nurse documented that report was called to another nursing facility and that all medications were being sent with the resident. A late entry by the President of Clinical Services stated that the resident was transferred to another nursing facility per his request, even though he was noted to be intoxicated at the time. The discharge plan of care only stated that he was discharged to another nursing home and that a medication list was faxed, with no further documentation explaining how the transfer decision was made, why his prior plan to discharge to family was no longer in place, how the receiving facility was chosen, or how it would meet his needs differently.

Additional documentation from the receiving facility showed that upon admission, staff there were uncertain about the amount of alcohol the resident had been consuming daily, what precautions to put in place given his limited access to alcohol, and had limited details about his fall. Later that evening, the resident complained of double vision, nausea, and had a prominent area above his left eyebrow, and he requested to go to the emergency room. Interviews at the sending facility revealed that the LPN observed the resident reeking of alcohol and appearing intoxicated, that the Administrator discussed his drinking and preferences with him, and that the Administrator did not know if the transfer had been discussed with the physician. The Administrator also stated that another facility had called asking if they had residents with behavior issues and that the resident had previously expressed a preference to move closer to another city, but the facility lacked staffing to find a placement where he wanted. There was no documentation in the record explaining the change from the original discharge plan to family, the rationale for the new facility choice, or how the transfer planning addressed his goals and needs.

For a second resident with respiratory failure, alcoholic cirrhosis, diabetes, alcohol abuse, viral hepatitis, PTSD, and bipolar disorder, the physician documented that she had been admitted after a hospital stay for alcohol detoxification and hypoxia, with heavy alcohol consumption prior to admission and a history of alcohol withdrawal seizures, and that she wished to transfer to a VA inpatient rehab program when a bed became available. Social services documented that she had been accepted for an inpatient rehab program at the VA with a tentative transfer date, and that she had authorization from the VA to stay at the facility for 30 days until that transfer. A nursing note then documented that the resident came to the facility, picked up her belongings and ordered medications, and was educated on her discharge and follow-up visit at the VA, with no further documentation regarding the reason for the discharge.

The Business Office Manager stated that when she left for the day, the plan remained for the resident to stay until transfer to the VA, and that a discharge would require a physician’s order or be handled as an against medical advice (AMA) discharge if the physician did not agree. The resident reported by telephone that she left the facility and went home, and that she was later admitted to the VA on the planned date. She stated that someone at the facility had talked to her about her leaving the facility every day to go home after therapy, and that after that conversation she decided to discharge home. The Director of Nursing confirmed there was no physician’s order to discharge the resident, no evidence the physician was aware of the discharge home, and that the discharge was not handled as an AMA discharge. The discharge plan of care only documented that the resident was discharged home, with no documentation explaining why she was discharged home instead of transferring to the VA as previously planned, and no evidence that the discharge planning process addressed her established discharge goals and needs.