Failure to Ensure Safe, Appropriate, and Properly Noticed Discharges for Two Cognitively Intact Residents
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning and execution for two cognitively intact residents, resulting in unsafe and inappropriate transfers/discharges. For the first resident, who had diagnoses including pulmonary embolism with acute cor pulmonale, acute respiratory failure, type 2 diabetes, presence of a cardiac pacemaker, anxiety disorder, depression, unspecified affective mood disorder, and Parkinson’s disease without dyskinesia, the facility arranged transportation through an outside transport company to return the resident to an assisted living facility (ALF). The social services director documented that transportation was scheduled for late afternoon on the day of discharge, but the clinical record contained no documentation of the actual pickup time. The transport company later reported that the request was canceled the same day because their required advance notice had not been met. On the day of discharge, the resident was removed from her room and placed in the activities room to wait for transportation. Multiple staff interviews indicated that the resident remained in common areas (activities room, dining room, lobby, and at the nurse’s station) asking about her ride as the afternoon and evening progressed. The assistant director of nursing stated that when he left the facility early in the evening, the resident was still asking about her ride and was told that the ALF was coming to pick her up. He later received text messages from an RN that the resident was anxious and wanted to leave, followed by a message that the resident had left. The nursing home administrator stated that staff assumed the resident had left with her transportation, even though no one actually saw her get into a vehicle and there was no documentation of her departure. The resident later reported that she had been waiting for transportation for hours, that “the big wigs left and the night nurses did not know what to do with her,” and that she eventually pushed open the door and left the building in her wheelchair without staff awareness. She stated she did not know the route to her ALF, did not have her phone, hearing aids, or dentures, and was self-propelling her wheelchair in the road when a couple stopped to help and called 911. An emergency department physician note documented that the resident said she had been waiting all day, became tired of waiting, left, and was found on the side of the street in her wheelchair before being brought to the ER by EMS. The ALF administrator reported that she was informed by the nursing home that the ALF had not picked up the resident, and later learned from a hospital case manager that the resident had been found on the side of the road and transported to the hospital. For the second resident, who had diagnoses including intervertebral disc degeneration, type 2 diabetes, insomnia due to other mental disorder, and depressive episodes, the facility failed to provide appropriate notice and justification for transfer and did not ensure the resident was discharged to the chosen destination. A psychology note shortly before discharge documented that the resident was unstable and having episodes of agitation due to situational concerns about being transferred to a new nursing home the following week. The discharge summary indicated the resident was being discharged to another nursing home in a different county, and a discharge order was entered without specifying the reason for transfer, level of care, or assistance needed. The written transfer and discharge notice given to the resident on the day of discharge stated that the reason for discharge was that the resident’s health had improved sufficiently so that he no longer needed the services provided by the facility, and documented that the resident refused to sign the notice. The resident later reported that he had been given three options of places to go and was told he would be evicted if he did not choose one, and that the facility told him they needed to free up his room because it was being converted to a different type of care. He stated that he chose a nursing home in one city but was instead transported to a nursing home in another city. The social services assistant stated that the resident chose the nursing home where he was sent, but also acknowledged that the resident was not given a 30‑day written notice of transfer and that there was no documentation of the verbal notice she said had been given three weeks earlier. She confirmed that the resident refused to sign the transfer form and that she was unsure why he was transferred. The nursing home administrator stated that the facility gives a 72‑hour notice if they cannot provide the skills or services to meet a resident’s maximum potential and that this resident was transferred because the facility was transitioning to more short‑term beds, and also acknowledged that the forms were not filled out correctly and there was no documentation that the resident agreed to transfer. The assistant director of nursing stated there was no medical reason for the transfer, the resident was not a danger to himself or others, still needed LTC, and that the receiving nursing home did not provide any additional care that their facility could not provide. The resident further reported that two days after arriving at the new nursing home he was hospitalized for medical complications, and that the new nursing home would not accept him back after his hospital stay. He stated that he then had to pay out of pocket for transportation back to his original city and was living in hotels because he had no home. Overall, the record review and interviews showed that the facility did not follow its own transfer and discharge policy requirements for notice, documentation of reasons for transfer, confirmation of transportation, and ensuring that discharges and transfers met residents’ needs and preferences and were carried out safely for both residents involved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe dementia and significant behavioral disturbances, including wandering, disrobing, inappropriate urination/defecation, and sexually inappropriate and aggressive behaviors toward others, was involved in a serious incident where he exposed himself, assaulted an LPN, and entered a female resident’s room naked, causing her to fall while trying to escape. Both residents were sent to the ER, and the administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others. However, surveyors found no documentation in the electronic health record of the immediate discharge, no record that the resident’s spouse was informed of the discharge and its reasons, and no scanned discharge notice. A separate paper folder contained a discharge notice inaccurately listing the discharge destination as the family home and notes about notifying the receiving facility and spouse, but the administrator confirmed this information was never entered into the electronic record, contrary to the facility’s discharge/transfer policy.
A resident with multiple chronic conditions and moderate cognitive impairment was discharged home without the facility involving her POA in the discharge planning process, despite documentation that the POA had previously provided input favoring long-term placement and a care plan intervention for social services to meet with both resident and family to determine the discharge plan. The resident met with a PA, signed a discharge packet with medication and home health orders, and was picked up by family on the day of discharge, but there was no documented consultation or prior notification to the POA. The DON acknowledged that the family was not included in the discharge discussion, which conflicted with the facility’s discharge planning policy requiring collaborative planning and documentation of resident and representative notification.
A resident with multiple chronic conditions, who was assessed as cognitively intact, was discharged without any documentation in the medical record of their discharge disposition, recapitulation of stay, or discharge arrangements. The record lacked a discharge summary, nursing discharge note, and post-discharge plan of care. The DON confirmed these omissions, which were inconsistent with the facility’s own policy requiring nursing to obtain discharge orders, prepare a discharge summary and post-discharge plan, and complete a discharge note prior to discharge.
Unsafe discharge without required notice: A resident with epilepsy, TBI, severe cognitive impairment, and ongoing behavioral symptoms was sent with her husband to an ER after staff-directed aggression escalated. The hospital did not admit her, the facility then refused readmission, and the resident was ultimately taken home. The record showed no discharge notice or appeal rights were provided before the discharge, and the facility’s own policy allowed discharge only under limited circumstances.
A resident with multiple complex conditions and severe cognitive impairment was issued a NOMNC by phone, then transferred to the hospital for elevated heart rate. The transfer form contained only clinical information and lacked evidence of a written transfer/discharge notice. The resident was taken off the census the same day, and after the BFCC-QIO later upheld the end of Medicare coverage, there was no documentation that the resident or representative was offered the option to return or stay on a private-pay basis or informed of service costs. The Administrator confirmed that no bed-hold notice or option to hold the bed was provided, the bed was not held during hospitalization, and the bed was reassigned so no bed was available when the resident was ready to return.
The facility failed to adequately plan and document safe, goal-directed transfers and discharges for two residents. One resident with a history of substance abuse and an established plan to discharge to family was transferred to another nursing facility while intoxicated after a fall, with no clear documentation of why his original discharge plan changed, how the receiving facility was selected, or how it would better meet his needs. Another resident with multiple medical and psychiatric diagnoses, admitted after alcohol detox and scheduled to transfer to a VA inpatient rehab program, was instead discharged home without a physician order, without being processed as an AMA discharge, and without documentation explaining the change from the planned transfer or how her discharge goals and needs were addressed.
Failure to Accurately Document and Record Immediate Discharge After Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an immediate discharge was accurately documented and included in the medical record for a resident with severe cognitive impairment and significant behavioral symptoms. The resident had vascular dementia, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, and generalized anxiety disorder, and required maximum assistance for most personal care. Physician orders included multiple psychotropic and mood-stabilizing medications, and an order for the resident to reside on a secured unit. The quarterly MDS documented severe cognitive impairment, hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering. From admission through discharge, nursing progress notes described escalating agitation and disruptive behaviors, including wandering into other residents’ rooms, placing items in toilets, exit-seeking, refusal of medications, and increasing aggression when redirected. The resident engaged in repeated episodes of public disrobing, inappropriate urination and defecation, and sexually inappropriate behaviors, such as entering female residents’ rooms naked and engaging in inappropriate sexual behavior on their beds, and attempting to rub feces on other residents. The resident was transferred twice for psychiatric evaluation due to behaviors the facility was unable to manage, including anxiety, aggression, exit seeking, sexual aggression toward females, and combative behavior resulting in self-inflicted injury. Despite these events, no interdisciplinary team notes discussing the resident’s behaviors were found in the record during the resident’s stay. On one evening, an LPN documented that the resident was in the hallway with genitals exposed, refused redirection to dress, became physically aggressive, and ripped the LPN’s shirt and pulled out her hair. The resident then entered a female resident’s room naked, claimed she was his wife, and forcefully attempted to get into her bed, causing the female resident to fall out of bed while trying to get away. Emergency services were contacted, and both residents were transferred to the ER for evaluation. After this event, there was no further documentation in the nursing progress notes regarding the resident’s discharge disposition. The Administrator later stated that an emergency discharge was issued due to the resident’s behaviors endangering others, but review of the electronic health record revealed no documentation of the immediate discharge, no record that the resident’s wife had been informed of the discharge and its reasons, and no scanned copy of the discharge notice. Further review showed that a written discharge notice, dated two days after the incident, inaccurately listed the discharge location as the family home, even though the resident had been transported to the hospital and did not return to the facility. The notice stated that the discharge was immediate due to behaviors endangering the safety of individuals in the home and included information on appeal rights and contact information for the Ombudsman and Administrator. The Administrator produced a separate folder containing a copy of the certified mail to the resident’s wife, an undated and unsigned note about a voicemail to the receiving facility’s social worker stating the resident could not return, and a narrative that the wife was notified of the emergent discharge and believed he would do better on an all-male secured unit. However, the Administrator confirmed that this information and the discharge notice had not been documented or scanned into the resident’s electronic health record, contrary to the facility’s Discharge/Transfer policy, which requires that unplanned discharge information and rationale be documented in the electronic record. The facility’s Discharge/Transfer policy, last revised in June 2025, outlined acceptable rationales for discharge or transfer, including behavioral issues that cannot be safely managed and that endanger others, and required that when unplanned discharges occur, the facility provide specific information in the discharge notice explaining why the resident is being discharged and how the discharge meets criteria, with this information documented in the resident’s electronic health record. In this case, the surveyors found that the facility failed to ensure the immediate discharge was accurately documented in the medical record and that the discharge notice contained accurate information about the discharge location, resulting in a deficiency for failure to ensure the transfer/discharge process met requirements for documentation and accuracy for this resident.
Failure to Involve POA in Discharge Planning
Penalty
Summary
The facility failed to include a resident’s family/Power of Attorney (POA) in the discharge planning process, contrary to the resident’s care plan and facility policy. The resident had multiple complex medical diagnoses, including encephalopathy, peripheral vascular disease, malnutrition, acute and chronic respiratory failure, emphysema, congestive heart failure, chronic kidney disease, and other chronic conditions, and had a BIMS score of 10 indicating moderate cognitive impairment. A care conference document showed the current discharge plan was for the resident to remain in the facility for long-term placement, with the resident present but her family not in attendance. The resident’s care plan documented that she wished to return to the community, but also reflected that, per the POA, she was considered a possible long-term placement. The care plan included an intervention that social services would meet with the resident and family on admission to determine the discharge plan. Progress notes showed that the resident met with a physician assistant to discuss an upcoming discharge home and that both the resident and the physician assistant signed the discharge packet, which included medication orders and home health orders. However, review of progress notes for the days leading up to the discharge revealed no evidence that the facility consulted with or notified the resident’s family or POA about the discharge prior to the day it occurred, when the family member received a call from the resident to pick her up. The family member, who confirmed she was the POA and wanted to be kept up to date on all care and changes, reported that she had not been consulted about this discharge and that prior notifications had been inconsistent. The DON confirmed that the discharge process had not been discussed with the family before it occurred, despite the care plan and the facility’s discharge planning policy requiring collaborative planning with the resident and representative and documentation of resident and representative notification.
Failure to Document Resident Discharge Disposition and Post-Discharge Plan
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s discharge disposition and required discharge information in the medical record. Surveyors reviewed the closed medical record of a resident who had been admitted with diagnoses including breast cancer, hypertension, major depressive disorder, and osteoarthritis. The resident was documented as cognitively intact on a quarterly MDS assessment completed shortly before discharge. Despite this, the record lacked documentation of where the resident went after discharge and did not contain the required discharge-related entries. Further review of the resident’s closed record showed there was no recapitulation of the resident’s stay and no progress notes concerning discharge arrangements. The medical record did not include a discharge summary or a post-discharge plan of care, and there was no nursing discharge note describing the resident’s disposition. These omissions meant that the medical record did not reflect the basis for the discharge, the discharge planning process, or the resident’s post-discharge care arrangements as required by regulation. During an interview, the DON confirmed that there was no documentation of the resident’s discharge disposition in the medical record. The DON also confirmed that there was no documented recapitulation of the stay and no nursing notes about the resident’s discharge disposition, and that a post-discharge plan was not documented. Review of the facility’s policy titled “Transfer or Discharge, Preparing a Resident for,” revised in 2016, showed that the policy requires development of a post-discharge plan for each resident prior to transfer or discharge, review of this plan with the resident and/or family at least 24 hours before discharge, and that nursing services are responsible for obtaining discharge orders, preparing the discharge summary and post-discharge plan, and completing a discharge note in the medical record. These required elements were not present in this resident’s record.
Plan Of Correction
F627 Inappropriate Discharge The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 53 no longer resides in the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents residing in the facility have the potential to be discharged. Census of 47. There are currently no residents being discharged from the facility as of 3/25/26 sweep completed by nurse manager. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced nursing management staff and social worker completed on 4/9/2026 a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment, preparing the discharge summary and post-discharge plan, and completing discharge notes in the medical record. How the corrective action will be monitored to ensure the deficient practice will not recur. An audit of all discharged residents for a proper discharge plan and documentation is in place 5x a week X4 weeks per DON/designee. If there are concerns identified with the discharge audit, the concern will be corrected at that time, and the nurse involved will be educated in the area of improvement. Results are presented to QAPI team weekly to evaluate areas of improvement.
Unsafe discharge without required notice
Penalty
Summary
The facility failed to ensure a resident was provided a safe and appropriate discharge. Resident #84 was admitted with diagnoses including epilepsy, traumatic brain injury, anxiety disorder, mood disorder, depression, tracheostomy status, and thyroiditis. The resident’s MDS showed a BIMS score of zero, indicating she was rarely or never understood, and a staff assessment noted short- and long-term memory problems. She required moderate assistance with toilet use, bathing, and dressing, and her care plan identified cognitive impairment, risk for falls, and mood and behavior concerns, including crying, yelling for help, repeated questioning, and removing her clothes and walking in the hallway. Progress notes showed the resident’s behaviors were directed toward staff and included hitting, kicking, throwing items, and hitting the medication cart against the wall. The record did not show behaviors directed toward other residents or herself. The DON documented that she was notified the resident was out of control, had hit a nurse, and police were called. The DON emailed the physician stating the facility was not equipped for the resident’s behaviors and asked about psychiatric placement options. The physician responded that a psychiatric facility with neurology onsite was needed, but she did not know of one that met that need, and suggested the resident’s husband take her to an ER with a psychiatric center. The resident was sent to a local hospital with her husband, but the hospital did not admit her. The facility then determined the resident could not return because she was considered a harm to herself and others, despite the record showing her behaviors were directed toward staff. The resident’s husband reported the hospital would not admit her and that he had no place to take her. The facility provided the husband with the resident’s medications and belongings, and the resident ultimately went home with her husband. The medical record contained no documentation that the facility provided the resident or her husband with a discharge notice or appeal rights before the discharge. The facility policy stated residents could remain in the facility except when the resident or responsible party requested discharge, payment was not being made, or the health and safety of the individual or other residents were endangered.
Failure to Provide Bed-Hold Notice and Permit Resident Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return after hospitalization and to provide required transfer/discharge and bed-hold notices. The resident, who had multiple complex diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, dysphagia, cognitive communication deficit, muscle weakness, gait abnormalities, and severe cognitive impairment (BIMS score of two), was admitted to the facility in early January. A Notice of Medicare Non-Coverage (NOMNC) was issued by social services via telephone to the resident’s responsible party, advising that Medicare coverage would end and that financial liability would begin on a specified date, and informing them of appeal rights. The resident was then transferred to the hospital for elevated heart rate and admitted for observation and treatment. The transfer documentation reflected only clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of transfer. The resident’s record showed that the resident was discharged from the facility and removed from the census on the same day as the hospital transfer. A subsequent BFCC-QIO determination letter documented that the resident lost the appeal of the NOMNC and no longer met Medicare coverage requirements for SNF services, and that the resident or representative was notified by telephone of the decision and of financial responsibility for continued services after Medicare coverage ended. However, there was no documentation in the medical record that the resident or representative was offered the option to return or remain at the facility on a private-pay basis or informed of the cost of services once Medicare coverage ended. The Administrator confirmed that no bed-hold notice was provided, no option to hold the bed was offered when the resident went to the hospital, the bed was not held during the hospitalization, and that by the time the resident was ready to return, the bed had been given to another resident and no bed was available for readmission.
Failure to Plan and Document Safe, Goal-Directed Transfers and Discharges
Penalty
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.
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