Failure to Explain Medicaid Share of Cost Before Eviction Notice: A resident with intact cognition and diagnoses including epilepsy, insomnia, and gait/mobility abnormalities was told about unpaid Medicaid share of cost and a pending discharge, but the charge was not fully explained by business office staff and/or the SSD. The SSD could not provide documentation that the share of cost was explained before the initial eviction notice was issued, despite the resident stating the amount was not clearly understood.
Unsigned Physician Discharge Summaries: The facility failed to ensure physician discharge summaries were signed and dated for three residents who were transferred or discharged. Two residents were sent to the hospital, including one after increased confusion and agitation and one after a fall, and one resident was discharged home with 24/7 HHC at a family member’s request. The ADON verified the discharge summaries were not signed and dated by the physician.
Failure to Readmit Resident After Hospitalization and Offer Bed Hold: A resident with Parkinson's disease and DM2 became verbally aggressive and waved bandage scissors at staff, was sent to the hospital on a 5150 hold, and was later found medically stable with psychiatry recommending return to the facility. The DON stated the facility refused readmission despite medical clearance and also stated residents should be offered a bed hold before transfer or within 24 hours, while facility policy required written notice of the 7-day bed hold right.
A resident was sent to the hospital for low Hgb and further evaluation, then later cleared by the hospital physician for discharge back to the facility. Facility staff refused readmission because of one HR reading of 45 bpm and believed the resident did not meet the admission criteria of a stable HR of at least 60 bpm, even though the resident had a bed hold, belongings still in the room, and the hospital CM reported the NP said the resident could return. Additional HR readings in the hospital record included 52, 58, 53, 56, 62, 45, and 52 bpm.
A resident with acute respiratory failure, COPD, muscle weakness, and type 2 DM was transferred to the GACH after chest pain and later cleared to return, but the facility did not readmit the resident when the GACH first called to confirm acceptance. The CL told the GACH the resident could return when ready and the DON reviewed the records and found readmission appropriate, yet the resident was not brought back until several days later. The DON stated the admission criteria policy was not followed.
A resident with cerebral infarction, gait and mobility impairment, and moderate cognitive impairment was discharged home without the recommended DME. The DOR documented that a FWW and BSC were needed for safe discharge, but the SSD only ordered a FWW and did not order a BSC, and the facility did not confirm whether the resident actually had a walker at home. The DON confirmed the equipment should have been available at discharge, and a family member stated the resident did not have a walker at home and was forgetful.
A resident with intact cognition and diagnoses including polyneuropathy and chronic pain was given a notice of transfer/discharge listing the discharge location as TBD, which she understood to mean to be determined. She refused to sign because she had nowhere to go and reported feeling distressed and anxious. The OMB said the resident needed a minimum 30-day written notice, while the family member denied receiving a meaningful discharge discussion. Facility notes and staff statements were inconsistent, and the discharge care plan had not been updated since 2021 despite active discharge planning.
A resident with intact cognition had no documented discharge plan in the EHR, and he stated he had asked the social services director about a plan but no one returned to discuss it. The ISSD confirmed there was no discharge planning documentation, and the DON stated discharge planning should have started on admission per facility policy.
A resident with paraplegia, muscle weakness, depressive disorder, and UTI was discharged before the outcome of an active appeal was received. Records showed the appeal was submitted before discharge, but the resident left the facility the same day and later won the appeal. Interviews with the ADC, SSD, and DON confirmed the resident should not have been discharged while the appeal was pending.
A resident with DM, prior CVA, left-sided weakness, and ongoing dependence for bathing, dressing, toileting, transfers, and ambulation was discharged to a hotel with her son as the primary caregiver. Social services and nursing noted concerns about the son’s unstable housing and behavior, but there was no documented APS notification. Therapy did not re-evaluate discharge readiness or complete caregiver training, and nursing provided medication teaching to the resident without return demonstration; the son was not present for discharge teaching or competency evaluation.
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