Failure to Arrange Safe and Orderly Emergency Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident when it processed an emergency discharge without securing an appropriate discharge location, supports, or housing. Facility policy on Discharge Planning, dated 01/09/2002, required Social Services to arrange or assist in arranging necessary services, identify the discharge location, supports, and equipment, and, for residents without an identified discharge location, enlist the support of the assigned Medicaid case manager and other public agencies to secure appropriate housing. The resident was admitted with diagnoses including atherosclerosis of coronary artery bypass graft(s). The Nursing Home Transfer or Discharge Notice, dated 01/29/2026, documented an emergency discharge under the reason that the safety of other individuals in the facility was endangered. The discharge location was recorded as "Car (Personal)" with the address listed as "NA," and the record did not identify an established discharge address or confirmed housing placement where the resident could access shelter or hygiene facilities. Interviews and record review confirmed that no confirmed housing placement was secured prior to discharge. The Administrator stated the discharge was processed as an emergency discharge with law enforcement present when the notice was delivered, and that the resident packed his belongings and left the facility the same day. The Social Worker stated the discharge was processed as an immediate discharge and confirmed that the discharge location was documented as the resident's car, with no confirmed housing placement arranged beforehand. The resident later reported being escorted from the facility by police on the date of discharge, and that his POA secured motel lodging for several days following discharge before he went to stay with a friend. The Administrator later acknowledged that discharge to a hotel would have been preferable to discharge to the resident's vehicle.
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