A resident with dementia, wandering, agitation, and behavioral disturbances repeatedly tried to leave, entered other residents’ rooms, and became physically aggressive toward staff. The facility discharged the resident AMA after escalating behaviors, but did not obtain a physician order for the transfer, did not timely notify the PCP or DON, and did not document proper discharge planning before sending the resident to the hospital.
A resident with intact cognition and diagnoses including diabetes, Parkinsonism, dementia, and schizophrenia repeatedly stated he wanted to leave and go somewhere else, but the facility did not develop or implement a discharge planning process tied to that request. The care plan focused on the resident remaining long term and did not address his desire to transfer, while staff gave conflicting accounts about when the request was reported and whether referrals were made.
Incomplete Discharge Summary and Assessment: A resident who requested transfer to another facility was discharged, but the EHR did not contain a completed discharge summary with a recapitulation of stay, final status summary, or medication reconciliation. The discharge planning review assessment also remained incomplete/unlocked in the record, and the DON confirmed the recapitulation of stay should have been completed.
Failed discharge planning led to unsafe transition and homelessness. A resident with SMI, cognitive impairment, meth use history, and PASRR-identified needs for psychiatric, behavioral health, substance use, and supported living services was discharged with a friend after requesting discharge. The care plan did not address PASRR requirements, the guardian was not notified, and the resident left without meds or coordinated supports. She resumed meth use, became homeless, and was later hospitalized in ICU on a ventilator after a drug overdose.
Failure to document basis for transfer and provide required notice: A resident with severe dementia, dependence for most ADLs, and a history of behavioral concerns was transferred to an affiliated facility without medical record documentation supporting why the move was necessary. The record showed a prior hypersexual incident and later a resident-to-resident physical contact event, but no documented ongoing resident-to-resident sexual behaviors after that point. The resident's rep was told of the transfer and later the discharge, but there was no evidence that the required 30-day notice was given to the rep or the LTCSO, and no physician documentation supported the discharge rationale.
A resident with TBI, cognitive impairment, and multiple chronic conditions was allowed to sign out AMA after a conflict over the smoking policy and was sent by cab to a homeless shelter without his meds. Staff did not involve the SSD before discharge, and the resident was later found confused, unable to explain where he came from or how he arrived, and unable to meet basic needs, leading to hospital admission on a court order.
A resident with multiple chronic conditions, intact cognition, and a history of depression and anxiety was involuntarily discharged to a homeless shelter after an episode of verbal aggression toward staff. The facility had previously issued unsigned 30‑day and same‑day involuntary discharge notices naming the shelter as the destination. On the day of discharge, an LPN reported the resident blocked her and threatened her during medication administration, the administrator called police, and the resident was ultimately removed in handcuffs. Staff interviews confirmed that no physician was notified, no physician order or updated assessment was obtained, and no comprehensive discharge summary, medication reconciliation, or post‑discharge plan of care was completed with the resident, despite facility policy requiring these steps for transfer/discharge, especially when behavior is cited as endangering safety. The Ombudsman was not notified of the discharge or police involvement, and there was no documented evidence that the resident was adequately prepared or oriented for a safe and orderly discharge.
A resident with UTI, depression, and vascular dementia was admitted for skilled therapy and expected to transition to LTC, but staff documented confusion, refusal of care and meds, and escalating agitation in the dining room. The resident yelled that she did not belong there, tried to kick and swing at staff, pushed her chair toward others, and later was found with her wheelchair tipped backward. The facility sent the resident to the hospital for acute behavior changes and discharged her because it could not accommodate her in memory care, and the DON later acknowledged the resident was not reassessed after transfer.
Failure to Document and Carry Out Active Discharge Planning: A resident with stroke, depression, and hemiplegia wanted to discharge to the community, but the facility could not produce documentation of active discharge planning for months. The resident had intact cognition, was largely independent with wheelchair mobility and ADLs, and repeatedly stated he wanted a handicap-accessible apartment. Notes showed discussions about housing barriers, waiver programs, and financial issues, but the MDS stated active discharge planning was not being done and no LCA referral had been made because the discharge date was more than 3 months away.
A resident with MS, functional quadriplegia, anxiety, and depression was transferred to a hospital with a UTI after staff reported multiple prior incidents involving marijuana or THC products and implemented a two-person rule for care. While the resident was hospitalized and reportedly medically ready to return, facility leadership repeatedly hand-delivered emergency involuntary discharge notices without performing an in-person or coordinated assessment for readmission and relied only on existing medical records. There was no contemporaneous documentation from the PCP or MD that the resident was a danger to self or others before the discharge notices, and the facility did not document the required elements of its transfer/discharge policy, such as unmet needs, attempts to meet those needs, and detailed discharge information. The resident, her family, and hospital staff described that she wanted to return, was tearful and anxious about the discharge, and that the facility refused readmission even after an ALJ overturned the discharge. The facility also failed to obtain the resident’s or the correct POA’s signature on the discharge summary, instead having a family member of uncertain legal status sign, and did not ask the medical POA to sign when he retrieved the resident’s belongings.
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