A resident was transferred to the hospital for evaluation after a change in condition and was not re-admitted afterward. An admission staff member said the resident had been on hospice and that hospice would not take the resident back, but could not explain why the resident was no longer considered a facility patient or whether a bed was available. Family members reported the facility never contacted them about re-admission, despite the facility policy stating residents are to be allowed to return after hospitalization regardless of payer source.
Failure to Readmit Resident After Hospitalization: A resident with ESBL-resistant infection, dementia, sepsis, and CRE was transferred to a hospital and placed on bed hold, but the facility refused readmission when the hospital said the resident was ready to return. Staff stated the resident was ambulatory, required isolation, and could not be accommodated, and the bed hold was removed early despite the facility policy stating the resident could return to an available bed.
A resident with lumbar and rib fractures, pain, and mobility limitations was approved for a short OOP but returned far beyond the authorized time. Staff did not document the resident signing out, did not complete a nursing or physical assessment on return, and finalized an AMA discharge after the resident refused to sign the form. The record also lacked required documentation of the reason for stopping care, clinical risk discussion, and post-discharge arrangements.
A resident with DM and a history of TBI was planned for discharge to a shelter, but Social Services did not document the discharge planning process, the resident’s involvement, or whether the shelter could meet his medical needs. The resident had intact cognition, used a walker or wheelchair, needed help with toileting and bathing, and said he had not received insulin or diabetes education before being told he would leave. The SSD stated there was no formal discharge meeting and that discharge discussions were tracked informally rather than in the medical record or care plan.
A resident was not re-admitted after hospitalization because the facility said no private isolation room was available. The IP and DON stated the resident was thought to have active MRSA involving the knee, but staff did not review the wound status, lab results, or hospital precaution orders before deciding on placement. The resident was later re-admitted in a shared room on EBP after the wound was closed and IV ATB was completed.
Delayed Readmission After Hospital Clearance: A resident with cholecystitis, CRE, and functional quadriplegia was cleared by the GACH to return to the LTC facility but was not readmitted because no male isolation bed was available. Staff later confirmed an empty room and then two female rooms with one occupant each that could have been rearranged to accommodate the resident, but the resident remained at the hospital instead of returning to the facility.
A resident with a G-tube, severe cognitive deficits, and prior CVA was discharged without the Kangaroo pump needed for continuous TF, and the family reported the resident missed a scheduled feeding at home. The facility later changed the order to bolus TF, but the family and HHRN stated they were not taught bolus administration, and key discharge records such as the H&P, discharge summary, progress notes, and special instructions were not sent to HH.
Failure to Notify Resident Representative of Proposed Discharge: A resident with dementia and severe cognitive impairment was discharged without the resident’s RP/POA receiving a written Notice of Proposed Transfer and Discharge. Records showed the resident was incapable of healthcare decisions, yet the discharge process relied on a phone call and did not document that the family member was given or sent the notice. The family member later stated she was unaware of the discharge, did not receive paperwork, could not appeal, and was not involved in choosing the discharge location.
Incomplete discharge planning documentation: A resident with bilateral hip pain, chronic pain syndrome, gait and mobility issues, asthma, and arthritis had intact cognition and decision-making capacity, but the facility had no IDT discharge planning notes, no physician progress notes stating the reason for discharge, and no discharge care plan with discharge goals. The DON verified the missing documentation, despite policy requiring discharge goals and documented reasons for transfer or discharge.
Improper Transfer/Discharge of Two Residents Without Medical Justification: Two residents were discharged from one SNF to another SNF that provided the same level of care without clear physician documentation supporting the move. One resident still had foot wounds and LTC needs, while the other had active foot wounds, DM with ulcer, cirrhosis, CHF, and COPD; the discharge paperwork contained conflicting or absent reasons, and interviews showed both residents felt pressured and were not given a choice.
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